Mucocutaneous and invasive candidiasis among very low birth weight (less than 1,500 grams) infants in intensive care nurseries: a prospective study.

To determine whether mucocutaneous candidiasis presages the development of invasive candidiasis and to assess factors influencing the development of mucocutaneous candidiasis and invasive candidiasis among infants requiring neonatal intensive care, all infants admitted to our neonatal intensive care unit during a 47-month period were prospectively examined twice weekly for mucocutaneous candidiasis. Because 16 of 18 (89%) infants in whom invasive candidiasis (defined by positive cultures of blood, CSF, deep tissue or greater than or equal to 2 supra-pubic urine aspirates) developed had birth weights less than 1,500 g, further analysis was focused toward the very low birth weight group. Of 358 very low birth weight infants hospitalized for less than three days and serially studied until discharge from the neonatal intensive care unit, mucocutaneous candidiasis developed in 28 (7.8%), invasive candidiasis developed in 16 (4.5%), and in 323 there was no evidence of mucocutaneous candidiasis or invasive candidiasis. Although many risk factors were shown by univariate analysis to be significantly more common among those with invasive candidiasis and mucocutaneous candidiasis, adjustment for the covariant effects of duration of hospitalization and gestational age revealed that only prolonged duration of antibiotic therapy and duration of endotracheal intubation were significantly associated with invasive candidiasis. Invasive candidiasis developed later in nine of 28 (32%) infants with mucocutaneous candidiasis despite nystatin therapy of mucocutaneous candidiasis in all nine (median duration of therapy before invasive candidiasis, nine days). Very low birth weight infants in whom mucocutaneous candidiasis develops are at significantly greater risk of invasive candidiasis developing later than those in whom mucocutaneous candidiasis did not develop (9/28 v 7/330, P less than .001).

Polymicrobial sepsis among intensive care nursery infants.

To determine the incidence, characteristics, and course of polymicrobial sepsis among infants in intensive care nurseries, we reviewed all such episodes in our neonatal unit from September 1971 through June 1986. We identified 15 episodes (3.9% of all cases of culture-proven sepsis during the survey period) in which blood or cerebrospinal fluid (CSF) culture yielded multiple organisms felt to represent true pathogens. Mortality associated with late-onset polymicrobial sepsis (7 of 10; 70%) was significantly higher (P less than .001) than in late-onset monomicrobial sepsis (86 of 370; 23%). Six patients were 37 weeks' gestation or greater at birth, and five were younger than 4 days of age when the polymicrobial culture was obtained. Group D streptococci were recovered in eight cases (53%). Gastrointestinal foci appeared to be common among infants with late-onset polymicrobial infection (5 of 10), while prolonged rupture of membranes was frequently associated with early-onset infection (4 of 5). Though recovery of multiple organisms from blood or CSF may not always be significant, one should not immediately assume contamination. A report of more than one organism growing from a normally sterile body fluid in an intensive care nursery infant should be considered significant, and therapy should be adjusted to provide appropriate antimicrobial agents for all reported organisms if the infant has not substantially improved in the interval since the culture was actually obtained.

The impact of gestational age on dysmaturity/postmaturity.

The medical records of 403 infants admitted to the neonatal intensive care unit were reviewed. All were postterm (greater than or equal to 42 weeks' gestation) infants or infants who were full term (greater than or equal to 38 weeks' gestation) and had clinical diagnoses associated with the neonatal postmaturity/dysmaturity syndrome. Data collected from these 403 records were used to generate frequency distribution tables for a variety of obstetric and neonatal outcome variables. Regression analyses were used to assess associations among these variables and the presence or absence of fetal malnutrition (dysmaturity) or postdatism. Fetal distress and neonatal acidosis were associated with both dysmaturity and postdatism. Primigravidas, meconium-stained amniotic fluid, cesarean section, birth trauma, and neonatal death were associated with postdatism but not with dysmaturity. Preeclampsia, maternal smoking, oligohydramnios, low Apgar score, neonatal pulmonary hypertension, neurologic abnormalities, and a need for extracorporeal membrane oxygenation were associated with dysmaturity. No interaction between postdatism and dysmaturity was seen for any outcome variable. Postdatism and dysmaturity appear to contribute risk factors independently to infants admitted to the intensive care unit.