Predictors of high maintenance prostaglandin E1 doses in neonates with critical congenital heart disease-ductal-dependent pulmonary circulation during preoperative care.

BACKGROUND: Neonates with critical congenital heart disease of the ductal-dependent pulmonary circulation type (CCHD-DDPC) require prostaglandin E1 (PGE1) to maintain oxygen saturation until surgery. However, the factors contributing to the maintenance doses of PGE1 remain unclear. This study aimed to determine the predictors of high maintenance PGE1 doses in these neonates. METHODS: This retrospective cohort study included neonates with CCHD-DDPC at Songklanagarind Hospital between January 1, 2006, and December 31, 2021. Factors associated with high maintenance PGE1 doses (> 0.01 mcg/kg/min) were analyzed to identify predictors. Odds ratios were calculated using tabulation and logistic regression analysis. A prediction score was developed for high maintenance PGE1 doses. RESULTS: Among 96 neonates with CCHD-DDPC, 55 % required high maintenance doses of PGE1. Three factors significantly associated with high maintenance PGE1 doses were patent ductus arteriosus (PDA) size-to-birthweight ratio ≤1.3 mm/kg, initial PGE1 dose >0.03 mcg/kg/min, and preoperative invasive mechanical ventilation. The area under the receiver operating characteristic curve for these three predictors was 0.7409. A predictive score of 0-3 was created based on these factors. The probabilities of receiving a high maintenance dose of PGE1 for patients with overall scores of 0, 1, 2, and 3 were 0.19 (95 % CI: 0.04-0.33), 0.42 (95 % CI: 0.30-0.54), 0.69 (95 % CI: 0.57-0.81), and 0.87 (95 % CI: 0.76-0.99), respectively. CONCLUSIONS: In neonates with CCHD-DDPC, a PDA size-to-birth weight ratio ≤1.3 mm/kg, an initial dose of PGE1 > 0.03 mcg/kg/min, and preoperative invasive mechanical ventilation were predictors of high maintenance PGE1 doses during the preoperative period.

Incidence and risk factors of transient hypothyroxinemia of prematurity: a prospective cohort study.

BACKGROUND: Transient hypothyroxinemia of prematurity (THOP) is characterized by low thyroxine (T4) levels with normal thyroid-stimulating hormone (TSH) levels. This study aimed to determine the incidence and factors associated with THOP. METHODS: This prospective cohort study included neonates who were born before 37 weeks of gestation in the neonatal intensive care unit (NICU) between April 2017 and December 2020. Serum TSH and free thyroxine (FT4) levels were routinely screened at 3-5 days and 2, 4, and 6-8 weeks postnatally. The criteria for diagnosis of THOP were a TSH level < 7 mU/L with a FT4 level < 0.8 ng/dL at any screening timepoint. RESULTS: The incidence of THOP in infants born before 28, 34, and 37 weeks of gestation was 39.5 (17/43), 8.4% (29/343), and 4.8% (35/722), respectively. A multivariate analysis revealed that a gestational age of < 28 weeks (adjusted odds ratio [aOR]: 5.35, 95% confidence interval [CI]: 1.89-15.13, p=0.002); 5-min Apgar score of ≤3 (aOR: 5.72, 95% CI: 2.2-14.89, p < 0.001); and treatment with aminophylline (aOR: 2.95, 95% CI: 1.08-8.11, p=0.037), dobutamine (aOR: 4.12, 95% CI: 1.55-10.98, p=0.004), or morphine (aOR: 4.91, 95% CI: 1.29-18.74, p=0.011) were associated with an increased risk of THOP. The TSH and FT4 levels in infants with THOP returned to normal ranges by 2 weeks of age. CONCLUSIONS: THOP is frequently found in preterm infants. An extremely low gestational age, a low Apgar score, and the use of certain medications in the NICU are risk factors for the development of THOP. Therefore, a thyroid screening program should be implemented for evaluating congenital hypothyroidism (CH) and THOP in preterm neonates in all settings.

Reintubation Rate between Nasal High-Frequency Oscillatory Ventilation versus Synchronized Nasal Intermittent Positive Pressure Ventilation in Neonates: A Parallel Randomized Controlled Trial.

OBJECTIVE: Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) were the new modes of noninvasive ventilation. This study's aim was to clarify as to which of the nHFOV and sNIPPV modes was superior in preventing postextubation failure or reintubation in neonates. STUDY DESIGN: An open-label parallel randomized study was performed. Extubated preterm and term neonates were randomly allocated into nHFOV or sNIPPV modes; the reintubation rate was evaluated within 7 days after extubation between the two modes. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. The sample calculation was 1,050 neonates; however, this trial was stopped early as enrollment was too slow. RESULTS: From July 2020 to June 2022, 202 neonates were assessed for eligibility and 69 neonates were excluded. Finally, 133 neonates were randomly allocated to the study interventions (nHFOV = 67, sNIPPV = 66). The median gestational age and birthweight were 33 (30-37) weeks and 1,910 (1,355-2,836) g, respectively. The reintubation rate within 7 days did not significantly differ between the groups (nHFOV [5/67, 7%] vs. sNIPPV [4/66, 6%]); risk difference [95% confidence interval] = 0.01 [-0.08 to 0.11]; p = 0.99), including preterm (nHFOV [4/55, 7%] vs. sNIPPV [3/44, 7%]) and very preterm (nHFOV [3/25, 12%] vs. sNIPPV [3/25, 12%]) neonates. CONCLUSION: After neonatal extubation, there was no significant difference of reintubation rates within 7 days between nHFOV and sNIPPV. This trial has been registered in the ClinicalTrials.gov database (https://clinicaltrials.gov/ct2/show/NCT04323397). First posted registration on March 26, 2020. KEY POINTS: · There was no significant difference of reintubation rates between nHFOV and sNIPPV.. · During nHFOV support, one neonate developed pneumomediastinum.. · During sNIPPV support, one neonate developed pulmonary hemorrhage..

Carbon Dioxide Level between Nasal High-Frequency Oscillatory Ventilation and Synchronized Nasal Intermittent Positive Pressure Ventilation after Extubation in Neonates: A Cross-over Randomized Controlled Trial.

OBJECTIVE: Nasal high-frequency oscillatory ventilation (nHFOV) and synchronized nasal intermittent positive pressure ventilation (sNIPPV) yield a lower partial pressure of carbon dioxide (pCO2) after extubation than nasal continuous positive airway pressure. Our aim was to clarify which of the two was superior. STUDY DESIGN: We performed a crossover randomized study to evaluate pCO2 level among 102 participants from July 2020 to June 2022. Intubated preterm and term neonates with arterial lines were randomly allocated to nHFOV-sNIPPV or sNIPPV-nHFOV sequences; their pCO2 levels were measured after 2 hours in each mode. Subgroup analyses were performed for preterm (gestational age <37 weeks) and very preterm (gestational age <32 weeks) neonates. RESULTS: The mean gestational age (nHFOV-sNIPPV, 32.8 vs. sNIPPV-nHFOV, 33.5 weeks) and median birthweight (1,850 vs. 1,930 g) did not differ between the sequences. The mean ± standard deviation pCO2 level after nHFOV (38.7 ± 8.8 mm Hg) was significantly higher than that after sNIPPV (36.8 ± 10.2 mm Hg; mean difference: 1.9 mm Hg; 95% confidence interval: 0.3-3.4 mm Hg; treatment effect [p = 0.007] but no sequence [p = 0.92], period [p = 0.53], or carryover [p = 0.94] effects). However, the difference in pCO2 level between the sequences was not statistically significant in the subgroup analyses of preterm and very preterm neonates. CONCLUSION: After neonatal extubation, the sNIPPV mode was associated with a lower pCO2 level than the nHFOV mode with no significant difference in preterm and very preterm neonates. KEY POINTS: · Full noninvasive ventilation support is suggested in neonatal ventilation.. · pCO2 level in sNIPPV was lower than in nHFOV.. · No differences in pCO2 levels were observed in either preterm or very preterm neonates..

Risk Factors for Mortality or Major Morbidities of Very Preterm Infants: A Study from Thailand.

OBJECTIVE: Very preterm neonates have high rates of composite outcomes featuring mortality and major morbidities. If the modifiable risk factors could be identified, perhaps the rates could be decreased especially in resource-limited settings. STUDY DESIGN: We performed a prospective study in a Thai neonatal intensive care unit to identify the risk factors of composite outcomes between 2014 and 2021. The inclusion criterion was neonates who were born in our hospital at a gestational age (GA) of less than 32 weeks. The exclusion criteria were neonates who died in the delivery room or had major congenital anomalies. The composite outcomes were analyzed by multivariable logistic regression with adjusted odds ratios (aORs) and a 95% confidence interval (CI). RESULTS: Over the 8-year study period, 555 very preterm inborn neonates without major birth defects were delivered. The composite outcomes were 29.4% (163/555). The medians (interquartile ranges) of GA and birth weights of the neonates were 29 (27-31) weeks and 1,180 (860-1,475) grams, respectively. By multivariable analysis, GA (aOR: 0.65; 95% CI: 0.55-0.77), small for GA (aOR: 4.93; 95% CI: 1.79-13.58), multifetal gestation (aOR: 2.23; 95% CI: 1.12-4.46), intubation within 24 hours (aOR: 5.39; 95% CI: 1.35-21.64), and severe respiratory distress syndrome (aOR: 5.00; 95% CI: 1.05-23.89) were significantly associated with composite outcomes. CONCLUSION: Very preterm infants who had a lower GA were small for GA, twins or more, respiratory failure on the first day of life, and severe respiratory distress syndrome were associated with mortality and/or major morbidities. KEY POINTS: · In very preterm neonates, the composite outcomes and mortality rate were 29.4 and 12.3%.. · Composite outcomes were associated with lower GA, SGA, multifetal gestation, intubation, and severe RDS.. · Mortality was associated with lower GA or Apgar score at 5minutes, SGA, and PPHN..

Risk Factors for 30-Day Mortality in Neonates With Carbapenem-resistant A. baumannii Sepsis.

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) sepsis is becoming an extreme threat caused by high-case fatality rates and poor prevention and control in ICUs worldwide. However, the risk of mortality among neonatal CRAB sepsis is still unclear. METHODS: A retrospective medical records review study, which aimed to identify the risk factors of mortality in neonates with CRAB sepsis (including both bacteremia and/or meningitis) in Thailand from 1996 to 2019. All cases featuring positive blood and cerebrospinal fluid cultures for CRAB were reviewed. A multivariable logistic regression model was analyzed for nonsurvivors and survivors of neonatal CRAB sepsis. RESULTS: In a 24-year period, 47 of these were identified with CRAB sepsis. The median (interquartile range) gestational age and birth weight were 30 (28-35) weeks and 1500 (933-2482) g, respectively. The 30-day case fatality rate was 55% (26/47). In multivariable analysis, nonsurvivors of neonatal CRAB sepsis were associated with congenital heart disease (adjusted odds ratio [OR] = 1.33; 95% CI 1.06-1.66, P = 0.02), CRIB II score ≥9 (adjusted OR = 1.65; 95% CI: 1.20-2.27, P = 0.004), severe thrombocytopenia (adjusted OR = 1.45; 95% CI: 1.09-1.94, P = 0.02), and septic shock (adjusted OR = 1.62; 95% CI: 1.33-1.99, P <0.001). CONCLUSION: The risk factors of mortality in neonates with CRAB sepsis are associated with congenital heart disease, CRIB II score ≥9, shock, and severe thrombocytopenia.

Correlation and prediction of arterial partial pressure of carbon dioxide from venous umbilical blood gases.

BACKGROUND: Arterial partial pressure of carbon dioxide (pCO < sub > 2 < /sub > ) samples are lower in children and higher in fetuses when compared with venous samples. The correlation and prediction of pCO < sub > 2 < /sub > from umbilical venous (UVBG) to umbilical arterial blood gas (UABG) dyad in neonates are identified. METHODS: A prospective study was performed from July 2018 to December 2019. Two dependent tests and a multivariate regression model were used to analyze the comparison and correlation tests. RESULTS: A total of 116 paired UABG and UVBG samples were obtained. The medians (interquartile ranges, IQR) were as follows: gestational age of 34 (29-37) weeks, birth weight of 2122 (1146-2839) g, and postnatal age of 2.3 (1.4-10.8) h. The median (IQR) pCO < sub > 2(UABG) < /sub > and pCO < sub > 2(UVBG) < /sub > measurements were 40.2 (33.5-45.8) and 40.4 (34.7-46.8) mmHg, respectively (rho = 0.75, p < 0.001). The median of the differences (IQR) in pCO < sub > 2(UABG) < /sub > and pCO < sub > 2(UVBG) < /sub > was -0.9 (-4.7 to 2.3) mmHg, (p = 0.06). The equation to predict pCO < sub > 2(UABG) < /sub > was 0.9 × pCO < sub > 2(UVBG) < /sub > + 4, as derived from simple linear regression. The best model for predicting pCO < sub > 2(UABG) < /sub > was 0.9 x pCO < sub > 2(UVBG) < /sub > - 0.7 × venous base excess + 0.6 × 5-min Apgar score + 6.1 × meconium aspiration syndrome - 7.7 × patent ductus arteriosus - 6.5 (adjusted r < sup > 2 < /sup > = 0.74). CONCLUSIONS: pCO < sub > 2(UVBG) < /sub > correlates with and can predict pCO < sub > 2(UABG) < /sub > . Therefore, pCO < sub > 2(UVBG) < /sub > can be applied to pCO < sub > 2(UABG) < /sub > in neonates for whom UAC insertion is unsuccessful or to avoid an arterial puncture.

Ventilator-Free Days in Neonatal Ventilator-Associated Pneumonia.

OBJECTIVE: This study aimed to compare the ventilator-free days (VFDs) at day 28 and the short-term outcomes in neonates with and without ventilator-associated pneumonia (VAP and non-VAP groups). STUDY DESIGN: We performed a cohort study in a Thai neonatal intensive care unit between 2014 and 2020 to identify the VFDs in VAP and non-VAP neonates. Univariate and multivariate analyses were performed. RESULTS: The incidences of VAP rates were 5.76% (67/1,163 neonates) and 10.86 per 1,000 (92/8,469) ventilator days. The medians (interquartile ranges [IQRs]) of gestational age and birth weight in the VAP versus non-VAP groups were 31 (27-35) versus 34 (30-38) weeks, and 1,495 (813-2,593) versus 2,220 (1,405-2,940) g (p < 0.001, both), respectively. The medians (IQRs) of VFDs at 28 days in the VAP and non-VAP groups were 5 (0-16) and 24 (20-26) days (p < 0.001). From the univariate analysis, the lower VFDs, longer ventilator days, and higher rates of moderate-to-severe bronchopulmonary dysplasia (BPD), postnatal steroids for BPD, length of stay, and daily hospital cost in the VAP group were significantly higher than in the non-VAP group. From the multivariate analysis, the VAP group had significantly lower VFDs (regression coefficient = -10.99, standard error = 1.11, p < 0.001) and higher BPD (adjusted risk ratio = 18.70; 95% confidence interval = 9.17-39.5, p < 0.001) than the non-VAP group. CONCLUSION: Neonatal VAP lead to lower VFDs and a higher frequency of BPD. A multimodal strategy with a VAP prevention bundle care should be used in indicated cases to reduce the occurrence of neonatal VAP. KEY POINTS: · The VFDs of the neonatal VAP was lower than reported in adult study.. · There are limited data on VFDs in VAP during the neonatal period.. · Neonatal VAP reduces VFDs and increases BPD rates compared with non-VAP infants..

Risk factors of transient tachypnea of the newborn developing into pulmonary hypertension of the newborn: a case-control study.

Background: Transient tachypnea of the newborn (TTN) is the consequence of delayed resorption of lung fluid. When TTN develops, the infant may develop severe hypoxemia and progress to persistent pulmonary hypertension of the newborn (PPHN). Objectives: To examine factors associated with the development of PPHN in TTN infants. Methods: This retrospective study comprised 23 infants in whom a diagnosis of TTN with PPHN (TTN-PPHN) was confirmed and 59 infants with severe TTN without PPHN who required mechanical ventilation between 2009 and 2018 at Songklanagarind Hospital, Thailand. Logistic regression was used to assess factors associated with TTN and PPHN. Results: The factors identified by univariate analysis that were associated with development of PPHN were oxygen saturation (SpO2) <90% and respiratory rate (RR) ≥70 breaths/min at the time of admission, mean airway pressure (MAP) ≥8 cmH2O, oxygen index (OI) ≥10, partial pressure of oxygen (PaO2) ≤60, partial pressure of carbon dioxide (PCO2) ≥45 mmHg, and infants who did not receive positive pressure ventilation (PPV). In multivariate analyses, RR ≥70 breaths/min (adjusted odds ratio [aOR] 9.96, 95% confidence interval [CI] 2.1-47.29, P < 0.001) and OI ≥10 (aOR 29.22, 95% CI 4.46-191.23, P < 0.001) remained statistically significantly associated with PPHN. Conclusions: High RR and high OI were factors associated with PPHN in TTN infants.

Correlation and Prediction of Oxygen Index from Oxygen Saturation Index in Neonates with Acute Respiratory Failure.

OBJECTIVE: The aim of this article was to evaluate the correlation between the oxygen index (OI) and the oxygen saturation index (OSI, measured by pulse oximetry and noninvasively) in neonates with acute respiratory failure and to predict the OI from the OSI. STUDY DESIGN: A retrospective cohort study was conducted in neonates requiring invasive mechanical ventilation who had arterial blood gas between 2018 and 2019 at a neonatal intensive care unit. The correlation between OI and OSI was analyzed by using the Pearson correlation coefficient. RESULTS: A total of 636 measurements from 68 neonates (35 preterm and 33 terms) were recruited into the study. There was a strong correlation between the OI and the OSI (r = 0.90) in all neonates. The correlation between the OI and the OSI in persistent pulmonary hypertension of the newborn, congenital cyanotic heart disease, and other causes of respiratory failure also showed a strong correlation (r = 0.88, 0.93, and 0.88, respectively). The correlation was strong in neonates with an oxygen saturation less than 85% (r = 0.88), those with oxygen saturation ranging from 85 to 95% (r = 0.87), and also in preterm and term infants (gestational age < 28, 28 - 34, 34 - 36, and ≥37 weeks, r = 0.87, 0.92, 0.89, and 0.90, respectively). There were strong accuracy measures of the OI for OI cutoffs of 5, 10, 15, and 20 (area under the curve > 0.85). The equation relating the OI and OSI was represented by: OI = (2.3 × OSI) - 4. CONCLUSION: The OSI has a strong correlation with the OI, is a reliable assessor of the severity of respiratory failure in neonates without arterial sampling, and has high accuracy when the OI is less than 40. KEY POINTS: · OSI is calculated as (FiO2 × mean airway pressure × 100)/SpO2.. · OSI is as effective tool as OI for assessing the severity of pediatric acute respiratory distress syndrome.. · OSI has a strong correlation with OI in neonatal respiratory failure..

Neonatal multidrug-resistant bacterial meningitis: a 29-year study from a tertiary hospital in Thailand.

INTRODUCTION: This study aimed to compare the risks and case fatality rate (CFR) between neonatal multidrug-resistant (MDR) and non-MDR meningitis. METHODOLOGY: a secondary analysis of a case-control studies in a Thai neonatal intensive care unit between 1990 and 2018 was performed. The pathogenic organisms causing neonatal meningitis were Staphylococcus aureus, Enterococcus spp., Enterobacteriaceae, Acinetobacter spp., and Pseudomonas aeruginosa. A MDR organism was defined as an isolate that was non-susceptible to at least 1 agent in at least 3 antimicrobial categories. The multivariate regression was analyzed for MDR and non-MDR samples of neonatal meningitis. RESULTS: Over a period of 29 years, the number of neonatal MDR and non-MDR meningitis cases were 17 and 21, respectively. The medians (interquartile ranges) of gestational age, birthweight and onset of meningitis were 35 (29.5-38) weeks, 1,945 (1,218-2,859) grams and 6.5 (2.8-17.9) days, respectively. The most common organism was Acinetobacter baumannii (32%). By multivariate analysis, neonates who had MDR meningitis were more likely to have a lower Apgar score at 5 minutes (adjusted odds ratio: 95% confidence intervals = 0.66 [0.44-0.99], p = 0.04). The crude CFR of neonatal meningitis was 32%. Non-survivors in MDR meningitis (58.8%) were significantly higher than non-MDR meningitis (9.5%, p = 0.004). The most common pathogen in non-survivors was carbapenem-resistant Acinetobacter baumannii. CONCLUSIONS: Neonatal MDR meningitis has an association with lower APGAR scores, and higher CFR as well as Acinetobacter baumannii. Multifaceted infection prevention, and control programs for MDR organisms are crucial, and must be strictly implemented in high MDR areas.

Neonatal Outcomes in Pregnant Women with Systemic Lupus Erythematosus: A 13-Year Experience in Southern Thailand.

OBJECTIVES: The purpose of the study was to determine the clinical features of NLE and to compare the neonatal outcomes between newborns born to pregnant women with SLE and healthy pregnant women. METHODS: We conducted a retrospective cohort analysis between 2007 and 2019 in a tertiary referral hospital in Thailand. A total of 118 pregnant women with SLE with 132 neonates compared with 264 randomly selected healthy pregnant women. RESULTS: The median (interquartile range) gestational age and birth weight of 132 neonates born to women with SLE were 37 (35-38) weeks and 2687 g (2045-3160 g), respectively. The clinical features of NLE infants were hemolytic anemia (8%), thrombocytopenia (2.7%) and hyperbilirubinemia (5.3%). There was no neonate with a congenital complete heart block or skin lesion. Moreover, logistic regression analysis found that neonates born to women with SLE increased the risk of preterm birth [odd ratio (OR) 8.87, 95% confidence interval (95% CI) 4.32-18.21, p < 0.001], low birth weight (OR 10.35, 95% CI 5.08-21.08, p < 0.001), birth asphyxia (OR 2.91, 95% CI 1.26-6.73, p = 0.011) and NICU admission (OR 4.26, 95% CI 2.44-7.42, p < 0.001). SLE disease activity and corticosteroid and azathioprine usage were associated with preterm delivery in pregnant women with SLE. CONCLUSION: The major clinical features of NLE patients were hematologic and hepatobiliary abnormalities in our study. Pregnancies with SLE dramatically increased the risk of preterm delivery and neonatal complications. LAY SUMMARY: Neonatal lupus erythematosus (NLE) is the consequence of the transplacental passage of autoantibodies to newborns during pregnancy. The clinical features of NLE infants in our study were hemolytic anemia (8%), thrombocytopenia (2.7%) and hyperbilirubinemia (5.3%). There was no neonate with a congenital complete heart block or skin lesion. We also compared the neonatal outcomes between 118 pregnant women with SLE and 264 randomly selected healthy pregnant women. Our study found that the neonates born to women with SLE increased the risk of preterm birth, low birth weight, birth asphyxia and NICU admission. Moreover, SLE disease activity and corticosteroid and azathioprine usage were associated with preterm delivery in pregnant women with SLE.

Risk Factors Associated With 30-Day Mortality Among Neonates With A. baumannii Sepsis.

BACKGROUND: Acinetobacter baumannii sepsis constitutes an extreme threat with a poor prognosis and is a difficult infection to control, especially in Asia. Moreover, a knowledge gap in the risk of mortality in neonatal A. baumannii sepsis still exists. METHODS: This study aimed to identify the risk factors of mortality in neonates with A. baumannii sepsis in Thailand from 1996 to 2019. A multivariable logistic regression model was analyzed for nonsurvivors and survivors of neonatal A. baumannii sepsis. RESULTS: In a 24-year period, 91 neonates with A. baumannii sepsis were reviewed. The median (interquartile range) gestational age and birth weight were 33 (28.5, 37.5) weeks and 1740 (987.5, 2730.0) g, respectively. The 30-day case fatality rate was 36.3% (33/91). In univariable analysis, nonsurvivors of neonatal A. baumannii sepsis was associated with smaller neonates, lower Apgar scores, septic shock, mechanical ventilation, umbilical catheterization, neutropenia, severe thrombocytopenia, carbapenem-resistant A. baumannii sepsis, inadequate empiric antimicrobial therapy, and acute kidney injury. In multivariable analysis, nonsurvivors of neonatal A. baumannii sepsis were associated with septic shock (adjusted odds ratio [OR] = 41.38; 95% confidence intervals [CI]: 3.42-501.13; P = 0.003), severe thrombocytopenia (adjusted OR = 33.70; 95% CI: 3.44-330.55; P = 0.002), and inadequate empiric antimicrobial therapy (adjusted OR = 10.05; 95% CI: 1.40-71.98; P = 0.02). CONCLUSION: In high multidrug-resistant areas, empiric treatment with broader spectrum antimicrobials should be considered in neonates with sepsis shock or severe thrombocytopenia.

Intervention to reduce carbapenem-resistant Acinetobacter baumannii in a neonatal intensive care unit.

OBJECTIVE: To investigate the effects of environmental cleaning and the installation of heat and moisture exchangers (HMEs) to reduce neonatal carbapenem-resistant Acinetobacter baumannii (CRAB) sepsis and colonization as well as antimicrobial use. DESIGN: We conducted a 7-year, quasi-experimental study. SETTING AND PATIENTS: All neonates admitted to a neonatal intensive care unit (NICU). METHODS: We compared the trends for CRAB sepsis and colonization before (period 1, 2011-2013) and after (period 3, 2015-2017) a 12-month intervention period in 2014 (period 2) to incorporate a combination of HME use and sodium hypochlorite cleaning (5,000 ppm in the NICU and 500 ppm in the neonatal environment) using interrupted time series analysis with segmented regression. RESULTS: During the 7-year study period, 3,367 neonates were admitted to the NICU; the prevalence rates of CRAB sepsis and endotracheal CRAB colonization were 0.5 per 1,000 patient days, and 19.4 per 1,000 ventilator days. A comparison of period 1 to period 3 showed significant decreases in the percentages of both CRAB of A. baumannii sepsis (100% versus 11%) and endotracheal colonization (76% vs 52%) following the introduction of disposable HMEs and sodium hypochlorite cleaning (both P < .001). In period 3, compared with period 1, segmented regression analysis showed significant reductions in endotracheal CRAB colonization per 1,000 ventilator days (ie, change in level) and both carbapenem and colistin use (changes in both level and slope) (P < .001). CONCLUSIONS: Interventions featuring environmental cleaning and use of HMEs led to a sustainable reduction of CRAB colonization coupled with a reduction in broad-spectrum antimicrobial use in the NICU.

Comparison of Endotracheal Reintubation between Nasal High-Frequency Oscillation and Continuous Positive Airway Pressure in Neonates.

OBJECTIVE: This study aimed to compare the endotracheal reintubation between nasal high-frequency oscillation (nHFO) and nasal continuous positive airway pressure (nCPAP) with face mask groups who were followed up for up to 7 days. STUDY DESIGN: We performed a retrospective cohort study of extubated neonates admitted between 2013 and 2017. We used a Cox's proportional hazards model to adjust for significant between-group differences in baseline characteristics. RESULTS: One hundred and ninety-nine neonates were on either nHFO or nCPAP after extubation. The median (interquartile range) gestational age and birth weight were 31 (29, 33) weeks and 1,450 (1,065, 1,908) grams, respectively. From the univariate analysis, gestational age, ventilator modes, mean airway pressure, fraction of inspired oxygen, oxygen index, caffeine therapy, and initial continuous positive airway pressure level were significantly different between the nHFO and nCPAP groups. There was no significant difference in the 7-day reintubation rate of neonates on nHFO compared with nCPAP (hazard ratio: 2.39; 95% confidence interval: 0.97-5.84; p = 0.05). By multivariate analysis, there was no statistically significant difference of reintubation rate between nHFO and nCPAP by Cox's proportional hazards model. CONCLUSION: The nHFO mode with face mask is the choice for noninvasive ventilation to prevent reintubation during the week following extubation.

Risk Factors for 30-Day Mortality in Neonatal Gram-Negative Bacilli Sepsis.

OBJECTIVE: Multidrug-resistant gram-negative bacilli (MDR-GNB) have emerged globally as a serious threat and with a high case fatality rate (CFR). STUDY DESIGN: We performed a case-control study in a Thai neonatal intensive care unit to identify the risk factors for 30-day CFR of GNB sepsis between 1991 and 2017. The CFR was analyzed by Cox's proportional hazards model. RESULTS: For 27 years, the percentage of MDR-GNB from GNB sepsis was 66% (169/257). The medians (interquartile ranges) of gestational age and birth weight of the neonates with GNB sepsis were 33 (29-38) weeks and 1,817 (1,100-2,800) grams, respectively. The 30-day CFRs of the neonates with MDR-GNB and non-MDR-GNB sepsis were 33% (56/169) and 20% (18/88), respectively, (hazard ratio [HR] = 1.74; 95% confidence interval [CI]: 1.03-2.97; p = 0.04). Using Cox's proportional hazards model, nonsurvivors in GNB sepsis were more likely to have septic shock (adjusted HR [aHR] = 6.67; 95% CI: 3.28-13.57; p < 0.001) or no microbiological cure (aHR = 10.65; 95% CI: 4.98-22.76; p < 0.001) than survivors. CONCLUSION: Neonates suspected of sepsis with septic shock need broad-spectrum empirical antimicrobial therapy until the second successive negative culture, especially in high MDR areas.

Clinical presentation and outcome in congenital pulmonary malformation: 25 year retrospective study in Thailand.

BACKGROUND: Congenital pulmonary malformations (CPM) are a group of rare abnormal lung development lesions that can have various presentations. The aim of this study was to define the differences in the clinical presentations of CPM in neonates, infants, and children, and to review the outcomes. METHODS: A retrospective study was conducted at a tertiary care hospital in southern Thailand between 1992 and 2016. RESULTS: Fifty-four patients were diagnosed with CPM, and the median age at onset was 1.7 months (IQR, 0.03-10 months). There were 33 cases (61.1%) of congenital pulmonary airway malformations, two (3.7%) of bronchogenic cyst, eight of (14.8%) congenital lobar emphysema, seven of (13.0%) pulmonary sequestrations, and four of (7.4%) congenital lung cysts. Twenty patients under 1 month old and 16 patients who were 1-12 months old had symptoms of respiratory distress. In contrast, 13 patients >1 year old had symptoms of pulmonary infection. There were significant differences in the numbers of patients who had cyanosis (P = 0.006), cough (P < 0.001), and fever (P < 0.001) between the three age groups. Thirty-eight patients (70%) required surgical treatment involving lobectomy (78.9%). Median follow-up duration was 28.1 months (IQR, 3.7-9.4 months). Nine of 10 patients had abnormal lung function tests, and 80.6% of patients had no subsequent limitations in physical activities. CONCLUSIONS: Respiratory distress is the important clinical feature in neonates and infants, whereas the signs of pulmonary infection usually occur in children >1 year old. Good outcomes usually occur after surgery but need long-term follow up including lung function assessment.