Brief comments on three existing approaches for managing neonates at risk of early-onset sepsis.

BACKGROUND: Growing concerns regarding the adverse effects of antibiotics during the first days of life and the marked reduction in the incidence of early-onset sepsis (EOS) are changing the clinical practice for managing neonates at risk of EOS. Strategies avoiding unnecessary antibiotics while promoting mother-infant bonding and breastfeeding deserve to be considered. MAIN BODY: We compare strategies for managing newborns at risk of EOS recommended by the American Academy of Pediatrics, which are among the most followed recommendations worldwide. Currently three different approaches are suggested in asymptomatic full-term or late preterm neonates: i) the conventional management, based on standard perinatal risk factors for EOS alone, ii) the neonatal sepsis calculator, a multivariate risk assessment based on individualized, quantitative risk estimates (relying on maternal risk factors for EOS) combined with physical examination findings at birth and in the following hours and iii) an approach entirely based on newborn clinical condition (serial clinical observation) during the first 48 h of life. We discuss advantages and limitations of these approaches, by analyzing studies supporting each strategy. Approximately 40% of infants who develop EOS cannot be identified on the basis of maternal RFs or laboratory tests, therefore close monitoring of the asymptomatic but at-risk infant remains crucial. A key question is to know what proportion of babies with mild, unspecific symptoms at birth can be managed safely without giving antibiotics. CONCLUSIONS: Both neonatal sepsis calculator and serial clinical observation may miss cases of EOS, and clinical vigilance for all neonates is essential There is a need to assess which symptoms at birth are more predictive of EOS, and therefore require immediate interventions, or symptoms that can be carefully reevaluated without necessarily treat immediately the neonate with antibiotics. Studies comparing strategies for managing neonates are recommended.

Neonatal bacterial meningitis.

Neonatal bacterial meningitis (NM) continues to be a serious disease with an unchanging rate of adverse outcome of 20-60%, despite a worldwide decline in mortality. The 3 major pathogens in developed countries are: Group B streptococcus, gram negative rods and Lysteria monocytogenes. Signs and symptoms of NM may be subtle, unspecific, vague, atypical or absent. In order to exclude NM, all infants with proven or suspected sepsis should undergo lumbar puncture. Positive culture of cerebrospinal fluid may be the only way to diagnose NM and to identify the pathogen, as CSF parameters Smay be normal at early stages and NM may occur frequently (up to 30% of cases) in the absence of bacteraemia. When NM is suspected, treatment must be aggressive, as the goal is to achieve bactericidal concentration of antibiotics and to sterilize CSF as soon as possible. Antibiotics should be administered intravenously, at the highest clinically validated doses. Empiric antibiotic treatment should include agents active against all main pathogens; currently the recommended empiric treatment of NM is ampicillin, plus an aminoglycoside and a third-generation cephalosporn. Therapy should be reassessed after cultures and antibiotic susceptibility is available. Prevention of neonatal sepsis, early recognition of infants at risk, prompt treatment and future adjunctive therapies will improve prognosis. Finally, we present the first preliminary Italian data on GBS meningitis. Data are obtained from an area-based study conducted In Emilia-Romagna during 2003 to 2009.

[Prophylaxis of group B streptococcal infections in the birth centers of Emilia Romagna]. / La profilassi dell'infezione da streptococco di gruppo B nei punti nascita della regione Emilia Romagna.

OBJECTIVES: In the last decade several guidelines for prevention of neonatal group B streptococcal invasive disease have been published, mainly based on administration of intrapartum antibiotics. The spread of such recommendations yielded a reduction of the early-onset disease. The aim of the study was to investigate the practices for prophylaxis of neonatal infection in our region during the 2000 and to standardize them according to the new available evidence. METHODS: We conducted a multicenter study in Emilia Romagna, sending by mail a detailed questionnaire to the 28 birth centers of our region. RESULTS: Fifteen centers answered to the questionnaire. The practices were often differing from the recommendations of scientific societies. The most sensitive methods to identify colonized women were not widely used. Colonized infants were frequently treated with antibiotics and discharged later from the nursery. The incidence of neonatal invasive diseases was low, but most centers did not regularly collect a blood culture before antibiotic treatment is started. CONCLUSIONS: Repeated meetings among centers promoted the diffusion of information, the implementation of a shared protocol and the spread of the practices. The results of such meetings will be evalued in the next months.

Antitransglutaminase enzyme-linked immune-adsorbed assay in coeliac disease diagnosis: evaluation of a diagnostic algorithm.

BACKGROUND: Tissue transglutaminase is the major autoantigen recognized in the sera of coeliac patients. An enzyme-linked immune-adsorbed assay based on tissue transglutaminase was recently used to measure serum tissue transglutaminase immunoglobulins A for coeliac disease diagnosis. OBJECTIVES: To determine the sensitivity, the specificity, the positive and negative predictive values of an immunoenzymatic assay based on guinea pig tissue transglutaminase, to compare antititransglutaminase immunoenzymatic assay to the antiendomysium immunofluorescent assay, and to define a cost-effective sequence to execute serum antibody determination in coeliac patients. METHODS: We assessed for coeliac disease antibodies 91 pediatric patients with symptoms suggestive of coeliac disease, and 23 patients with coeliac disease on a gluten-free diet as controls. RESULTS: Antitransglutaminase immunoglobulins A showed 93.1% sensitivity, 93.6% specificity, 87.1% positive and 96.7% negative predictive values. Antitransglutaminase immunoglobulins A were significantly higher in antiendomysium positive subjects. Correlation between antitransglutaminase immunoglobulins A and antigliadin immunoglobulins A was not significant. DISCUSSION: Our results show that antitransglutaminase immunoenzymatic assay represents a cost-effective strategy for patients' serological evaluation and it could substitute EMA determination, which could be considered a second level evaluation.

Distribution and abundance of four caiman species (Crocodylia: Alligatoridae) in Jaú National Park, Amazonas, Brazil.

Jaú National Park is a large rain forest reserve that contains small populations of four caiman species. We sampled crocodilian populations during 30 surveys over a period of four years in five study areas. We found the mean abundance of caiman species to be very low (1.0 +/- 0.5 caiman/km of shoreline), independent of habitat type (river, stream or lake) and season. While abundance was almost equal, the species' composition varied in different waterbody and study areas. We analysed the structure similarity of this assemblage. Lake and river habitats were the most similar habitats, and inhabited by at least two species, mainly Caiman crocodilus and Melanosuchus niger. However, those species can also inhabit streams. Streams were the most dissimilar habitats studied and also had two other species: Paleosuchus trigonatus and P. palpebrosus. The structure of these assemblage does not suggest a pattern of species associated and separated by habitat. Trends in species relationships had a negative correlation with species of similar size, C. crocodilus and P. trigonatus, and an apparent complete exclusion of M. niger and P. trigonatus. Microhabitat analysis suggests a slender habitat partitioning. P. trigonatus was absent from river and lake Igapó (flooded forest), but frequent in stream Igapó. This species was the most terrestrial and found in microhabitats similar to C. crocodilus (shallow waters, slow current). Melanosuchus niger inhabits deep, fast moving waters in different study areas. Despite inhabiting the same waterbodies in many surveys, M. niger and C. crocodilus did not share the same microhabitats. Paleosuchus palpebrosus was observed only in running waters and never in stagnant lake habitats. Cluster analysis revealed three survey groups: two constitute a mosaic in floodplains, (a) a cluster with both M. niger and C. crocodilus, and another (b) with only C. crocodilus. A third cluster (c) included more species, and the presence of Paleosuchus species. There was no significant difference among wariness of caimans between disturbed and undisturbed localities. However, there was a clear trend to increase wariness during the course of consecutive surveys at four localities, suggesting that we, more than local inhabitants, had disturbed caimans. The factors that are limiting caiman populations can be independent of human exploitation. Currently in Amazonia, increased the pressure of hunting, habitat loss and habitat alteration, and there is no evidence of widespread recovery of caiman populations. In large reserves as Jaú without many disturbance, most caiman populations can be low density, suggesting that in blackwater environments their recovery from exploitation should be very slow.