Invasive disease due to extended spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal unit: the possible role of cockroaches.

We recently experienced an outbreak of nosocomial disease due to extended spectrum beta-lactamase-producing Klebsiella pneumoniae in a neonatal unit infested with cockroaches. Organisms isolated from cockroaches were indistinguishable by pulsed-field gel electrophoresis from those colonizing infants or causing clinical disease using. Cockroach elimination together with standard infection-control measures resulted in control of the outbreak. We suggest cockroaches are possible vectors of pathogenic bacteria in the hospital environment.

Capillary refilling time in newborn babies: normal values.

AIM: To assess the normal values of capillary refilling time (CRT) in healthy newborn babies; to assess the effect of different nursery containers (incubator, radiant warmer, crib), phototherapy, birthweight, gestational age, size for gestational age and sex on CRT; to compare CRT at different body sites as well as to assess the variation between observers. METHODS: Healthy neonates (n = 469) of different gestational ages and different sizes for gestational age, were studied 1 to 7 days after birth. CRT was measured in four of the most suitable sites-namely, midpoints of the sternum and the forehead, the palm of the hand and the plantar surface of the heel (defined as chest, head, palm and heel, respectively). The applied pressing time was 5 seconds. CRT was measured with a manual stopwatch. RESULTS: Only the chest and the head distribution curves followed the Gaussian curve. The mean values and standard deviation of CRT in all tested nursery containers, including phototherapy for the chest, ranged from 1.82 (0.34) seconds to 2.01 (0.423) seconds, and for the head from 1.59 (0.36) seconds to 1.83 (0.31) seconds. The mean value of chest CRT was always longer than the head CRT for all parameters. Significant differences were found between different nursery containers, receivers, and non-receivers of phototherapy and between observers. No difference was found between sex, birthweight, gestational age and size for gestational age. CONCLUSIONS: The upper limit of normal for neonatal CRT was 3 seconds. Nursery containers, phototherapy, and observers produced significantly different results, but the differences were not clinically important. CRT values of the midpoints of the sternum and the forehead are the most consistent.

Clinical outcome of HIV positive patients with moderate to severe burns.

Human immunodeficiency virus (HIV) infection is a world wide and growing problem. Little is found in the literature concerning the treatment and outcome of patients suffering from HIV infection who are treated for burns. The aim of this study was to assess whether the outcome of HIV positive patients suffering from burn wounds differed from those who do not have HIV infection. Thirty three patients formed the HIV positive study group. HIV negative controls were matched for age, degree of burns, sex and inhalation injury. The mean age of the patients was 31.6 years and the mean total body surface burn was 26.4%. There was no significant difference in the outcome of the two groups in terms of mortality or treatment parameters measured. Two patients had stigmata of AIDS (tuberculosis) and both died. One patient, with a CD4 count of 228, developed severe necrotizing fasciitis. In keeping with other studies looking at the outcome of HIV positive patients in an Intensive Care Unit setting, we concluded that a HIV positive patient, who suffers from a burn wound and has no stigmata of AIDS, should be treated similarly to a HIV negative patient.

Capillary refilling time in newborns--optimal pressing time, sites of testing and normal values.

Aspects of capillary refilling time (CRT) in newborns, such as pressing time, sites of testing, normal values and difference between observers were assessed. CRT was measured in 280 term newborns, divided into 7 groups of 40 each, varying pressing time (from 1 to 7 s) was applied. CRT was measured in midpoints of forehead and sternum and plantar surface of heel (defined as head, chest and heel). No statistically significant difference was found between 3 and 7 s pressing time groups. The data points of the CRT of the head and chest approached normality, whilst those of the heel were widely scattered. Normal CRT in newborns is <3 s. No significant difference between two observers in head and chest CRT values was found.

Compliance of the respiratory system as a predictor for successful extubation in very-low-birth-weight infants recovering from respiratory distress syndrome.

OBJECTIVE: To develop additional criteria to predict for successful extubation of very-low-birth-weight infants recovering from respiratory distress syndrome. DESIGN: Prospective study. SETTING: Neonatal intensive care unit at a university teaching hospital. INTERVENTIONS: Infants ready for extubation according to clinical, ventilatory and blood gas criteria were studied. Before extubation, tidal volume (Vt), minute ventilation, respiratory rate/Vt and mean inspiratory flow were measured during two different ventilatory settings: (i) during intermittent mandatory ventilation (IMV); and (ii) while breathing spontaneously with endotracheal continuous positive airway pressure (CPAP). Tidal volume was obtained through electronically integrated flow measured by a hot-wire anemometer. Total respiratory compliance (Crs) was determined during IMV and was derived from the formula Vt/PIP-PEEP, where the difference between peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) represented the ventilator inflation pressure. MEASUREMENTS AND MAIN RESULTS: Each of 49 infants was studied once before extubation. 33 infants (67%) were successfully extubated and 16 (32.6%) required reintubation. Infants in the success and failure groups were matched for gestation, post-conceptional age, study weight and methylxanthine therapy at the time of study. Successful extubation was associated with a higher mean absolute Crs value (ml/cm H2O) specific Crs value (standardised for body length; ml/cm H2O/cm) compared with infants in whom extubation failed (0.67 v. 0.46; P = 0.01 and 0.018 v. 0.014; P = 0.03, respectively). Analysis of ROC curves detected thresholds for Crs (0.5 ml/cm H2O) and Vt (7 ml) for predicting successful extubation. An absolute Crs value 0.5 ml/cm H2O or more improved the likelihood of successful extubation when compared with clinical/ventilator and blood gas criteria. The likelihood of successful extubation was 81% if the Crs value was > or = 0.5 ml/cm H2O. A tidal volume of 7 ml or more was less sensitive in contributing to successful extubation (sensitivity 69%). The major causes for extubation failure included atelectasis (diffuse and/or localised) and the presence of a patent ductus arteriosus. CONCLUSIONS: In addition to following very precise ventilatory criteria for extubation, we found that bedside measurement of total respiratory system compliance added to the likelihood of extubation success in infants recovering from respiratory distress syndrome. Prospective studies are needed to validate the findings of this study.

Postnatal zidovudine in prevention of vertical HIV-1 transmission in a service setting.

We sought to determine the efficacy of a 4-6 week course of zidovudine (ZDV) in a group of infants exposed to HIV-1. A retrospective chart review was conducted on HIV-1-exposed neonates identified from February 1998 to August 1999. These infants received ZDV and their mothers were counselled regarding the risks and benefits of breastfeeding. After informed consent was obtained, the HIV-1-status of the infant was determined by RNA-PCR after 1 month of age. Thirty-three HIV-1-exposed neonates were identified; seven infants were excluded, five because of insufficient data and two because of maternal ZDV administration. In all but three, the diagnosis was suspected because of maternal illness, 19 of 26 mothers having either stage 3 or 4 disease. The transmission rate was 15.4 per cent (4 of 26). Errors in ZDV administration were detected in 20 neonates of whom four were infected (p = 1; Fischer's exact test). Antenatal diagnosis of HIV-1 status was associated with fewer medication errors in HIV-1-exposed neonates (p = 0.017, Fisher's exact test). It was concluded that a transmission rate of 15.4 per cent in symptomatic mothers suggests efficacy. Under similar circumstances, transmission rates varying between 37 and 67 per cent have been reported. Antenatal diagnosis is significantly associated with compliance to the regimen. Early identification of at-risk neonates and familiarity with the regimen may improve the outcome.

Is nCPAP of value in extreme preterms with no access to neonatal intensive care?

This prospective study was undertaken to investigate the efficacy of nasal continuous positive airway pressure (nCPAP) in a group of extremely small infants denied access to a neonatal intensive care unit (NICU) in South Africa. Consecutive infants weighing less than 1200 g and/or of a gestational age below 28 weeks admitted to the neonatal ward with respiratory distress syndrome (RDS), and who were refused admission to the NICU, received either nCPAP (Infant Flow System E.M.E., UK) of headbox oxygen. Of 22 infants, 11 infants were included in the treatment group (nCPAP) and 10 in the control group. Within the first 24 h, two infants (18 per cent) in the nCPAP group and eight infants (80 per cent) in the control group died (p = 0.007) (survival OR = 18; RR = 4.09). A statistically significant improvement in the arterial-alveolar (a/A) oxygen ratio occurred in the nCPAP group between postnatal day 1 and day 3 of life (0.17 vs. 0.36; p < 0.005). Neonatal complications occurred in six (55 per cent) infants who survived the first 24 h of life. Eighty per cent of the infants with intraventricular haemorrhage (IVH) died, as well as all the infants who were born before arrival at the hospital. At the time of discharge from hospital, 45 per cent (five infants) in the nCPAP group survived vs. 20 per cent (two infants) in the control group. The neurodevelopmental outcome of six of the surviving seven infants were evaluated at 1 year of corrected age. The neurodevelopmental outcome as assessed by the Griffith Score was within normal limits in all infants. One infant has sensorineural deafness and one is deaf and has a possible mild spastic diplegia (both in the treatment group). We conclude that nCPAP significantly improves the short-term survival of very low birth-weight (VLBW) infants with moderate to severe respiratory distress syndrome who could not be admitted to intensive care. nCPAP significantly improves the a/A oxygen ratio between day 1 and day 3 of life.

The transport of neonates to an intensive care unit.

OBJECTIVE: To describe the mode of transport, the type of patient transferred and outcome as defined by death or discharge from hospital. DESIGN: A retrospective study was done of all neonates transferred from outside the designated drainage area of the hospital. SETTING: The study was done at the level 3 Neonatal Intensive Care Unit at Tygerberg Hospital for the period January-September 1992. PARTICIPANTS: From a total of 58 infants 52 were enrolled; they originated over a vast area of the western and northern Cape Province. MAIN OUTCOME MEASURES: Reasons for transfer, mode of transport and survival were measured. RESULTS: None of the infants died during transport. In total 11 (21%) of the 52 died. Categorising outcome according to transport method showed 100% survival of babies transported by fixed-wing aircraft, 94% survival if transport was by helicopter, and 70% survival if transported by ambulance. The non-survivors had a higher mean gestational age (P < 0.05) than the survivors and included 8 (73%) with asphyxia-related meconium aspiration syndrome. When the primary referral diagnosis was considered, 8 (27%) of 29 infants with respiratory failure of any cause, and 2 (28%) of those with neurological problems, died. All the infants transported because of a surgical emergency survived. CONCLUSION: These results show a high survival rate in transported infants, with the highest mortality in the asphyxia-related meconium aspiration syndrome and the infants transported by ambulance. The preponderance of infants with meconium aspiration syndrome might reflect the standard of perinatal care provided in the outlying regions of the western and northern Cape.

Comparison of a new desktop spirometer (Diagnosa) with a laboratory spirometer.

BACKGROUND: The Diagnosa is a fully integrated system, able to determine spirometry, ECG, blood pressure and body composition. Real time data can be transferred via Internet to a remote receiving center. OBJECTIVES: The aim of this study was to perform biological testing of the spirometry component in subjects with normal and pathological pulmonary function. METHODS: A group of 45 patients (mean age 43.3 years, 30 males) was tested on both the Diagnosa and the standard Jaeger Masterlab spirometer according to the guidelines of the American Thoracic Society. Three subgroups of 15 subjects each (normal spirometry, obstructive and restrictive airflow limitation) were selected. RESULTS: All measurements performed with the Diagnosa (FVC, FIVC, FEV(1), PEF, FEF(25), FEF(50), FEF(75)) correlated closely (r = 0.92-0.99) with those performed with the Jaeger spirometer and showed good limits of agreement (the largest difference between the two devices being 0.2 liter for FEV(1)). Analysis of the 3 subgroups showed no difference for any parameters compared to the overall group. Electronic transfer of all data was successful. CONCLUSIONS: The Diagnosa spirometer is comparable to a standard laboratory spirometer and can be used reliably for telemedicine purposes.

Chest radiographs of neonates with respiratory failure caused by congenital syphilis.

Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.

The Changing Face of Neonatal Intensive Care in South Africa

In 1991 a cut-off weight of 1 000 g and/or 28 weeks' gestation for neonatal intensive care unit (NICU) admission was decided on by attending neonatologists at a Priorities in Perinatal Care Conference. These recommendations were not based on published evidence. At the time there were few data on the outcome of babies born in the public sector who received NICU. Aim. The aim of this study was to describe the demographic data (mother and baby) and outcomes of babies admitted to a tertiary NICU. Methods. During 1992 - 1996 (1992 cohort) and 1999 - 2000 (1999 cohort) two cohorts of babies treated in the NICU at Tygerberg Hospital; Western Cape; South Africa; were studied. Demogra- phic data were collected prospectively on all admissions with a birth weight of less than 1 501 g and a gestational age of less than 32 weeks. Outcome data were survival; days of ventilation and NICU stay. Results. There were 455 babies in the 1992 cohort and 272 in the 1999 cohort. The mothers' mean income was R892 per month and was higher in the 1999 cohort.The 1999 cohort comprised significantly smaller babies; at a mean birth weight of 1 119 g v. 1 198 g. The mean gestational age in the 1999 cohort was lower (29.2 v. 30.3 weeks); but so was the mortality rate (21.6v. 26.1). The main differences between the survivors and non-survivors were in their birth weight and gestational age and the mean income of their mothers. The mean number of ventilation days needed by these infants was low at 8.5 days; with an average stay in the NICU of 13 days. Discussion. Babies admitted to an NICU have a good chance of survival at a low mean number of ventilation and NICU days. The increase in survival in the 1999 cohort; in spite of low income; is in keeping with international trends and underlines the good short-term outcome of these small babies

Predictors of Survival in Infants with Congenital Diaphragmatic Hernia - Systemic Oxygenation Status Versus Dynamic Compliance of the Respiratory System

Objective. To compare whether early measurement of blood gases and/or dynamic compliance of the respiratory system (CRSdyn) predicts outcome in high-risk infants with unilateral congenital diaphragmatic hernia (CDH). Patients and methods. A retrospective study was performed at Tygerberg Children's Hospital between January 1992 and August 2001. High-risk infants with unilateral CDH; who presented with respiratory distress within 6 hours of birth; were included. Patients with other lethal congenital abnormalities were excluded. The first arterial blood gas value after endotracheal intubation was documented and the arterial-alveolar oxygen tension (a:A) ratio was calculated. CRSdyn was measured within 24 hours of birth. The ability of these measurements to predict outcome (survival or death during the newborn period) was determined. Results. Seventeen of 40 infants with CDH were categorised as high risk and included in the study. Eight of them (47) survived the neonatal period. The best single predictors of outcome were; in order; partial pressure of oxygen in arterial blood (PaO2); a:A ratio and dynamic compliance of the respiratory system standardised for body weight (CRSdyn/kg). The specificity and sensitivity at a PaO2 cut-off of 19.3 kPa were 7/8 (95confidence interval (CI): 0.473 - 0.997) and 9/9 (95CI: 0.634 - 1.000) respectively. Results for a:A ratio were cut-off 0.321; specificity 6/8 (95CI: 0.349 - 0.968); and sensitivity 9/9 (95CI: 0.634 - 1.000). Results for CRSdyn/kg were cut-off 0.259; specificity 6/8 (95CI: 0.349 - 0.968); and sensitivity 9/9 (95CI: 0.634 - 1.000). A linear discriminant function based on the 3 best single predictors was found to be no more effective than the first PaO2. Conclusions. Early oxygenation status predicts outcome better than the CRSdyn/kg in infants with unilateral CDH. However; both measurements predict outcome with high accuracy