Epidemiology of neonatal group B streptococcal disease in the Netherlands before and after introduction of guidelines for prevention.

OBJECTIVES: (1) To describe the epidemiology of neonatal group B streptococcal (GBS) disease over five years (1997-2001) in the Netherlands, stratified for proven and probable sepsis and for very early (<12 h), late early (12 h - <7 days) and late (7-90 days) onset sepsis. (2) To evaluate the effect of the introduction in January 1999 of guidelines for prevention of early onset GBS disease based on risk factors. METHODS: Data on cases were collected in collaboration with the Dutch Paediatric Surveillance Unit and corrected for under-reporting by the capture-recapture technique. RESULTS: Total incidence of proven very early onset, late early onset and late onset GBS sepsis was 0.32, 0.11 and 0.14 per 1000 live births, respectively, and of probable very early onset, late early onset and late onset GBS sepsis was 1.10, 0.18 and 0.02 per 1000 live births, respectively. Maternal risk factors were absent in 46% of the proven early onset cases. Considerably more infants with proven GBS sepsis were boys. 64% of the infants with proven very early onset GBS sepsis were first born compared with 47% in the general population. After the introduction of guidelines the incidence of proven early onset sepsis decreased considerably from 0.54 per 1000 live births in 1997-8 to 0.36 per 1000 live births in 1999-2001. However, there was no decrease in the incidence of meningitis and the case fatality rate in the first week of life. The incidence of late onset sepsis also remained unchanged. CONCLUSION: After the introduction prevention guidelines based on risk factors there has been a limited decrease in the incidence of proven early onset GBS sepsis in the Netherlands. This study therefore recommends changing the Dutch GBS prevention guidelines.

Diagnosis of enterovirus infection in the first 2 months of life by real-time polymerase chain reaction.

During summer and fall, enterovirus infections are responsible for a considerable proportion of hospitalizations of young infants. We prospectively studied the incidence of enterovirus infections via real-time polymerase chain reaction (PCR) in blood, feces, and cerebrospinal fluid samples from infants

Host defence to bacterial infection in the neonate.

Host defence to bacterial infection is mainly determined by opsonins, i.e., IgG antibodies and complement, and phagocytic cells, which co-operate to remove bacterial invaders from host tissues. Various studies have clearly documented distinct defects in both arms of host defence in the newborn period. Chemotaxis, i.e., directed migration of polymorphonuclear leukocytes (PMN) is impaired in the neonate. Phagocytosis of bacteria by neonatal PMN is normal, but post-phagocytic events, particularly metabolic activation and bacterial killing are impaired, the latter defect apparently due to diminished generation of reactive oxygen species. Both classical and alternative pathway activity of complement are mildly diminished (50-80% of adult values) in the term newborn, but are more severely decreased in the premature infant (20-40% of adult values in 28 to 36 weeks prematures). Opsonic activity of transplacentally-derived IgG when compared to maternal IgG is strikingly deficient against staphylococci and group B streptococci (GBS), in the latter case depending on the GBS serotype. Since opsonization is a key process in antibacterial defence, it is speculated that these opsonic defects of IgG may be an essential determinant of the neonate's susceptibility to disease due to these bacteria.

Development of resistance to aminoglycosides among coagulase-negative staphylococci and enterobacteriaceae in a neonatal intensive care unit.

A prospective study of the development of resistance to aminoglycosides among coagulase-negative staphylococci (CNS) and Enterobacteriaceae (ENT) was conducted for all patients admitted to a neonatal intensive care unit (NICU) from October 1985 to January 1990. A change in antibiotic regimen from gentamicin to amikacin occurred in January 1986, due to widespread gentamicin resistance among CNS, the most important cause of nosocomial infections in this NICU. From 657 patients, 884 faecal cultures, 1505 cultures from the respiratory tract and 152 blood cultures were included in the study. After its introduction, susceptibility to amikacin decreased rapidly in faecal and respiratory CNS isolates (from 62% to 28% and from 58% to 23% respectively). During the first half year, resistance to amikacin in faecal CNS isolates developed more rapidly among antibiotic-treated patients than among patients not treated with antibiotics. Susceptibility to amikacin in CNS blood isolates decreased more slowly, from 94% to 58% in 1987, while subsequently an increase in susceptibility was observed to about 80% in 1989. The same difference in development of resistance in faecal and respiratory CNS isolates compared to CNS blood isolates was noticed for gentamicin and tobramycin. In contrast, ENT remained highly (85-100%) susceptible to amikacin, gentamicin and tobramycin throughout the study period. It was concluded that four years after its introduction amikacin still appeared to be a valuable antibiotic in combination treatment of the vast majority of clinically important infections occurring in our NICU, since both Enterobacteriaceae and the majority of CNS blood isolates proved to be susceptible to this agent.(ABSTRACT TRUNCATED AT 250 WORDS)

An outbreak of gastroenteritis due to Escherichia coli 0142 H6 in a neonatal department.

An outbreak of gastroenteritis due to Escherichia coli 0142 H6 in a neonatal ward is described. The epidemic affected 16 of 24 infants (infection-rate 66 per cent), of whom one died due to necrotizing enterocolitis. Administration of antibiotics was of limited value in treatment or in eradicating E. coli 0142 H6 from the stools. Termination of the epidemic was only accomplished by isolating the patients, accompanied by strict hygienic measures, including the use of disposable gloves. Gastroenteritis due to this organism occurred only in prematurely born infants during the first 2 weeks of life.

Early neonatal group B streptococcal disease: degree of colonisation as an important determinant.

During a period of 5 years (1 January 1977 to 1 January 1982) 145 infants colonised with group B streptococci (GBS) were admitted to the neonatal intensive care unit of the University Children's Hospital, Utrecht. In 87 of these infants (60%) vertical transmission of GBS was established; in 43 of these 87 infants (49%) the degree of colonisation was moderate to heavy. Early-onset (EO) GBS disease arose in 21 of 145 infants (attack rate: 14.5%). Of the 43 infants moderately to heavily colonised with GBS, however, 19 suffered from EO GBS disease (attack rate: 44.2%), whereas there were only two cases among the 44, lightly colonised infants (attack rate: 4.5%), a highly significant difference (P less than 0.0005). Similarly, probable sepsis (PS), defined as signs and symptoms of sepsis but without positive blood cultures, was observed significantly more often in moderately to heavily colonised infants (15/43, attack rate: 34.9%) compared with those lightly colonised (4/44, attack rate: 9.1%) (P less than 0.005). Infants moderately to heavily colonised with GBS at birth appear to have a significantly higher risk of developing serious GBS disease (EO or PS) than do infants only lightly colonised.

Perinatal risk factors for cranial ultrasound abnormalities in neonates born after spontaneous labour before 34 weeks.

OBJECTIVE: The aim of this study was to identify risk factors for cranial ultrasound abnormalities in neonates born after spontaneous preterm labour with or without prolonged premature rupture of the membranes (PROM). METHODS: The presence of intraventricular haemorrhage and cystic periventricular leucomalacia was investigated in a cohort of neonates born between 24 and 34 weeks using cranial ultrasound. A stepwise forward logistic regression was performed to analyse the influence of antenatal and postnatal variables on cranial ultrasound abnormalities. RESULTS: The study group consisted of 205 neonates and cranial ultrasound abnormalities were identified in 27 infants. Early onset neonatal infectious disease (OR 3.09, 95% CI 1.24--7.70, P=0.01) increased the risk for cranial ultrasound abnormalities. Gestational age at birth (OR 0.96, 95% CI 0.93--0.99, P=0.03) and a full course of antenatal steroids (OR 0.33, 95% CI 0.13--0.85, P=0.02) reduced the risk for cranial ultrasound abnormalities. CONCLUSION: Early onset neonatal infectious disease is an independent risk factor for cranial ultrasound abnormalities in the very preterm neonate born after spontaneous labour with or without PROM.

Antenatal ultrasonographic diagnosis of a congenital posterolateral diaphragmatic defect.

The antenatal ultrasonographic findings in a fetus with a left-sided congenital posterolateral diaphragmatic defect (CPLDD) are presented and discussed. Displacement of the heart towards the right and absence of a normally positioned fluid-filled stomach at repeated examinations are diagnostic. In the event of an intrathoracically displaced fetal stomach, which occurs in about 60% of the cases, a sonolucent area in the left chest may be found. In view of the dynamic nature of fetal stomach filling, more than one examination may be required to detect this feature. Antenatal recognition of congenital diaphragmatic hernia (CDH) has important consequences for perinatal management and can improve neonatal outcome.

[Chickenpox in pregnancy with serious consequences for both mother and child]. / Waterpokken bij een zwangere met ernstige gevolgen voor moeder en kind.

A 41-year-old woman with chickenpox in the third trimester of her pregnancy was admitted to the Intensive Care Unit of our hospital for ventilatory support. She was treated with aciclovir, amoxicillin-clavulanic acid and erythromycin. Her baby was delivered by forceps following placental abruption. After delivery, both mother and child recovered slowly but could eventually leave the hospital in good condition. If a pregnant woman without a prior history of varicella-zoster infection is exposed to a child that has chickenpox, passive immunisation with varicella-zoster immunoglobulin should be administered. This reduces the risk of maternal complications and may prevent a fetal varicella syndrome. If the mother has already developed chickenpox and there are serious complications, she should be treated with intravenous aciclovir. If possible, delivery should be delayed until 5 days after the onset of maternal chickenpox.

[Diagnosis of infection in full-term infants born after prolonged status of ruptured membranes: clinical observation is sufficient]. / Infectiediagnostiek bij à terme pasgeborenen na langdurig gebroken vruchtvliezen: klinische observatie is voldoende.

We retrospectively studied our strategy in 80 full-term newborns, born more than 24 hours after rupture of amniotic membranes. Six patients developed clinical signs of sepsis, in four of them sepsis was proven by a positive blood culture. In all cases, clinical symptoms were the first sign of infection. Routine laboratory tests (CRP, leucocyte counts and differentiation, thrombocyte counts) and microbiological investigations (surface cultures, cord blood cultures) were not helpful for the diagnosis of infection at an early stage. These findings are in accordance with the literature. We conclude that after prolonged rupture of membranes with full-term newborns postnatal paediatric care can be limited to a close observation period of 48 hours. There is no need for any further routine investigation of infants without clinical signs of infection.

[Congenital infection: diagnostic serology of the mother not always definitive]. / Congenitale infectie: serologische diagnostiek bij de moeder niet altijd afdoende.

In 2 infants, a girl and a boy, congenital viral infection was diagnosed in the neonatal period. The prenatal examination (serologic investigation for Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus and syphilis (TORCHES)) was negative. In both cases prenatal ultrasonography was abnormal and suggested intrauterine infection. The infants were born with typical symptoms of multisystem disease, known as symptomatic congenital cytomegalovirus infection (jaundice, petechiae, hepatosplenomegaly, intrauterine growth retardation, microcephaly and cerebral calcifications) and congenital rubella syndrome (intrauterine growth retardation, congenital heart disease, cataract, hepatosplenomegaly and cerebral calcifications), respectively. Both had severe cerebral damage. To diagnose severe congenital infection in the first trimester of pregnancy in presence of congenital anomalies in utero there are other possible methods than TORCHES investigation, such as polymerase chain reaction and virus culture in amniotic fluid or in foetal blood obtained by cord puncture.

[Lithium poisoning in a newborn infant]. / Lithiumintoxicatie bij een pasgeborene.

We describe a newborn with a lithium intoxication. Her mother used lithium during her entire pregnancy. The intoxication was successfully treated with an exchange transfusion.

[Hepatitis B in children]. / Hepatitis B bij kinderen.

Central to immunization programmes is that hepatitis B virus infection in infancy is much more likely to result in the chronic carrier state than if infection occurs in adulthood. In areas of high endemicity like south-eastern Asia most infections occur when chronically infected women transmit hepatitis B virus to their newborns or when chronically infected children transmit the virus to other children. In the Netherlands, the endemicity is considered low; seroprevalence studies showed that 0.8% of the pregnant women are HBsAg-positive. To prevent mother to child transmission of hepatitis B a national immunization program has recently been implemented to prevent perinatal infection in approximately 450 neonates each year. Horizontal transmission of hepatitis B virus also seems possible in children since persistent carriers are found in (medical) centres and institutions for mentally handicapped. Since hepatitis B infections acquired during early childhood are likely to progress to chronicity and liver disease in adult life some risk factors for children in the Netherlands to contract hepatitis B infection are described and the immunization strategy is discussed.

[Premature infants and hepatitis B vaccination. Study Group Prevention Neonatal Hepatitis B]. / Prematuren en hepatitis B-vaccinatie. Werkgroep Preventie Neonatale Hepatitis B.

Since 1986 health authorities in the Netherlands advise to vaccinate preterm infants at similar age as term infants, without correction for their shortened gestational age. This advice was based on a study, which showed comparable immune responses after DTP vaccination in preterm and term infants. To assess the immunogenicity of hepatitis B vaccination not corrected for gestational age in preterm infants, we compared the antiHBs titer after hepatitis B vaccination in 44 preterm infants with the antiHBs titer in 829 term infants. More than 95% of the preterm infants developed an adequate immune response (> 10 IU/l antiHBs), irrespective the vaccination scheme which varied in vaccine dose, the number of vaccinations and the onset of the first vaccination. The percentage preterm infants with an antiHBs titer > 10 IU/l (98%) was not different of the corresponding percentage of term infants (98%). Similarly, no difference between preterm and term infants was observed when an antiHBs value of 100 IU/l was considered a positive response, neither when active immunisation started at month 0 or month 3. The geometric mean titre at 12 months of age was considered.

[Chylothorax in the neonatal period]. / Chylothorax in de neonatale periode.

The data of 11 infants with chylothorax in the neonatal period, seven with congenital chylothorax and 4 infants with iatrogenic chylothorax are reported. Chylothorax in the neonatal period may cause birth asphyxia and serious respiratory problems. Among the infants with congenital chylothorax diagnosis can be established before birth by ultrasound technique, followed by optimal resuscitation to prevent asphyxia. In most of the cases, conservative treatment with continuous drainage and total parenteral nutrition is sufficient.

[Thoracic pelvic phalangeal dystrophy (Jeune's syndrome)]. / Thoracic pelvic phalangeal dystrophy (Jeune syndroom).

The authors describe the clinical histories of four patients with a thoracic pelvic phalangeal dystrophy (Jeune syndrome). A short survey of the literature and a differential diagnosis are given.