Early Neonatal Sepsis Research Articles

No Change in Antibiotic Susceptibility Patterns in Two Neonatal-Units Over Two Decades

Aims: Identifying trends in the microorganisms causing early and late neonatal sepsis, analyze their antibiotic susceptibility, and evaluate the validity of the empirical treatment protocols. Methods: A 17-year (1993-2009) retrospective analysis of positive blood and CSF cultures in two neonatal intensive-care units at the Hadassah Medical Centre. Results: 991 infants (7.25/100 admissions) had at least one episode of either bacteraemia or meningitis. The overall incidence rate per 100 admissions was 0.68 for early bacteremia (p for trend=0.71), and 7.5 for late bacteremia with a positive trend (p=0.021). The incidence of early onset GBS bacteraemia decreased significantly (p=0.036). Among late bacteremias, Gram-positive and fungi infection rates were stable (p=0.64, 0.19 respectively), while Gram-negative infection rates showed a significant positive trend (p=0.007), with a peak between the 6th and 11th day. Fungemia was sporadically scattered starting at the 2nd week. Sensitivities to our empirical protocols did not change over the study period. Conclusions: Our empiric antibiotic protocols are valid despite their use over the last 17 years. This was achieved by the use of a controlled antibiotic program and maintaining high infectious control standards. Figure Figure

Neonatal bacterial sepsis: risk factors, clinical features And short term outcome

Background: Neonatal infections are afrequent and important causes of neonatal morbidity and mortality especially in the developing countries.Objective: The aim of the study is to determine the clinical picture, risk factors associated with neonatal sepsis and to estimate short term outcome from neonatal sepsis and its relation to birth weight, gestational age, onset of sepsis and type of bacteria.Patients and Methods: A prospective study was conducted on 80 neonates presented with sepsis who had been admitted to intensive care unit in Children Welfare Teaching hospitals in Baghdad over six months period between (15th of January 2008 to 15th of June 2008).A thorough history and physical examination were carried out, and samples of blood were taken for blood culture and sensitivity.Results: Eighty neonates were studied, sepsis was confirmed by clinical and laboratory measures. Fifty five (68.7%) neonates were males and 25(31.2%) were females. Fifty four (67.5%) were preterm and 26 (32.5%) were full term. Fifty nine (73.25%) neonates were still alive during period of hospitalization and discharged home, while 21 (26.25%) neonates died. Early onset sepsis was detected in 26 (32.5%) neonates while late onset sepsis was detected in 54 (67.5%) neonates, However, the death rate was higher in early onset sepsis (57.7%) compared to late onset sepsis (18.5%). The death rate was higher in neonates with maternal history of prolonged rupture of membrane >18 hours (54.8%), also it was increased when there was fever or infection during pregnancy.Conclusions: The study showed that the most common neonatal risk factors that increase the incidence of mortality were early neonatal sepsis, home delivery, prolonged rupture of membrane more than 18 hours and maternal fever or infection, and the most common features were lethargy, absence or weak moro reflex and reluctant to feed, The most common bacteria isolated from blood cultures was E. coli.

Antibiotic Therapy in Neonatal and Pediatric Septic Shock

Severe sepsis accounts for nearly 4,500 deaths (mortality rate 10%), and is responsible for nearly $2 billion annual healthcare expenditure in the United States. Early and speedy treatment of critically ill septic patients can halt or reduce the likelihood of physiologic progression to multi-system organ failure. A cornerstone of this therapeutic strategy is antibiotic administration. In this review, we discuss the empirical treatment strategies for the treatment of early and late neonatal sepsis, along with pediatric sepsis. Furthermore, we discuss the rationale that underlies the adoption of such treatment strategies. The present article also discusses the emergence of multi-drug organisms as the causative agents for sepsis, i.e. methicillin-resistant Staphylococcus aureus (MRSA), resistant enterococci and Klebsiella pneumoniae carbapenemases (KPC).

Sepsis in Neonatology Unit of Kirkuk Pediatric Hospital

This is a retrospective study reviewed all neonates who were proved to have sepsis by positive blood culture and admitted to the neonatal unit of Kirkuk pediatric hospital from June 1, 2005 to May 31, 2006. Data regarding gestational age, gender, causative microorganisms, drug sensitivity, time of presentation and outcome were collected and analyzed. The result of the study showed higher frequency of neonatal sepsis in premature neonates 12.41% in premature newborns VS. 4.41 % in fullterm neonates). No significant statistical differences were found in outcome between early and late neonatal sepsis. Also it was found that gender had no significant effect in the frequency of neonatal sepsis. Most common causative microorganism for both early and late neonatal sepsis found to be Klebsiella followed by E Coli. Mortality rate was (50.64 %) Most dead infants had early neonatal sepsis (34.18%), while only (16.46%) died from late neonatal sepsis.

AO-06. Live versus recorded lullabies for infants of less than 32 weeks' gestation

HOX B3 positive structures appeared mainly in the syncytiotrophoblast and Hofbauer cells. Abundance of HOX B3 was observed in Hofbauer cells of a 29 week placenta and a term placenta, both cases of early neonatal sepsis; syncytiotrophoblast of those placentas showed an occasional number of positive structures. The other term placentas showed occasional to numerous number of HOX B3 positive structures in the Hofbauer cells; occasional to moderate in the syncytiotrophoblast. Other pre-term placentas revealed few structures in the Hofbauer cells and few to moderate structures in the syncytiotrophoblast. The least number of both structures (none to occasional) was observed in three cases: two term—one healthy child, the other child with brain death, and a 23 weeks case.

1388 Assessment of a Series of Markers as Diagnostic Tools of Early-Onset Neonatal Sepsis

Aim: The aim of the research was to evaluate the usefulness of Toll-like receptors 2(TLR-2) and 4(TLR-4), interleukine-6(IL-6), tumor necrosis factor-alpha(TNF- α) and C-reactive protein(CRP) in diagnosis of early neonatal sepsis on preterm babies with premature rupture of membranes.Material and Methods:A prospective study has carried out between jan.2007-jan.2008 at Neonatology Department of the Cluj District University Hospital.Diagnosis of sepsis was done according to International Sepsis Definitions Criteria. Study group involved 21 newborns with symptoms suggestive of systemic infection, requiring sepsis evaluation, antibiotic treatment and control group represented by healthy newborns. We determined in the first day of life TLR-2, TLR-4, IL-6, TNF-α and CRP and in the third day the same without TLR. We used latex agglutination test for CRP, Elisa technique for TNF-α and IL-6 and flow cytometry for TLR. Data were analyzed using Statistica 6.0.Results: Sepsis group presented in the 1st day: TNF-α (pg/ml)= 14,7[5,0-24,3]; IL6 (pg/ ml)=153,7[82,3-225,1]; CRP (mg%)= 0,83[0,54- 1,12]; and the expression(%) of TLR2 = 42,5 [29,5- 55,4]; and TLR4 = 2,2[1,26-3,15]. TNF- α was correlate significantly and negative with TLR2. TLR2 was correlated significantly and positive with TLR4. In the 3-rd day the values were: TNF-α (pg/ml)= 10,1[5,1-15,1]; IL6(pg/ml)=46,5[16,3-76,7]; CRP (mg%)= 1,2[0,6-1,81]. Control group presented: TLR2(%) = 5,69 (p= 0,00006) and TLR4(%) = 0,67(p = 0,037).Conclusions: IL-6 and TNF-α can be considered markers of early-onset neonatal sepsis. TLR-2 and TLR-4 could be promising markers for neonatal sepsis. CRP revealed not to be a useful marker in diagnosis of early-onset sepsis.

PP-325. Features of early neonatal sepsis at newborns

PP-325. Features of early neonatal sepsis at newborns

Randomized controlled trial of probiotics for the prevention of spontaneous preterm delivery associated with intrauterine infection: study protocol.

BackgroundSpontaneous preterm deliveries that occur before the 34th week of gestation, and particularly before the 32nd week of gestation, have been strongly associated to intrauterine infection, ascending from vagina, and represent the largest portion of neonatal deaths and neurological problems. Bacterial vaginosis, characterized by a diminished or absent flora of lactobacilli and increased colonization of several anaerobic or facultative microorganisms, increases two times the risk of preterm delivery before the 34th week. Trials of antibiotics failed to show efficacy and effectiveness against spontaneous preterm birth related to bacterial vaginosis. Some studies indicate benefit from selected probiotics to treat genitourinary infections, including bacterial vaginosis.ObjectiveThe purpose of this study is to evaluate the effectiveness of the early administration of selected probiotics to pregnant women with asymptomatic bacterial vaginosis/intermediate degree infection to reduce the occurrence of spontaneous preterm delivery and related neonatal mortality and morbidity.Methods/DesignWomen attending public prenatal care services in Rio de Janeiro will be screened to select asymptomatic pregnant women, less than 20 weeks' gestation, with no indication of elective preterm delivery. Those with vaginal pH > = 4.5 and a Nugent score between 4 and 10 (intermediate degree infection or bacterial vaginosis) will be randomized to either the placebo or the intervention group, after written informed consent. Intervention consists in the use of probiotics, Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14, 2 capsules a day, each capsule containing more than one million bacilli of each strain, for 6-12 weeks, up to the 24th-25th wk of gestation. Ancillary analyses include quantification of selected cervicovaginal cytokines and genotyping of selected polymorphisms. The randomization process is stratified for history of preterm delivery and blocked. Allocation concealment was designed as well as blinding of women, caregivers and outcome evaluators. The study will be supervised by an independent monitoring committee. Outcomes under study are preterm delivery (< 34- < 32 weeks of gestation) and associated neonatal complications: early neonatal sepsis, bronchopulmonary dysplasia, periventricular leukomalacia, necrotizing enterocolitis, and prematurity-related retinopathy; definitions were adapted from those recommended by the 2002 version of the Vermont-Oxford Network. Trial registration at NIH register: NCT00303082.

Transabdominal Amnioinfusion in Preterm Premature Rupture of Membranes

Preventing premature rupture of membranes (pPROM) is a major concern of obstetricians. It occurs in 45% of all preterm deliveries and accounts for 20% of all cases of perinatal mortality. Evidence exists that prolonging time in utero after pPROM can enhance survival. Some studies have reported a significant increase in the pPROM-delivery interval after amnioinfusion. These same reports have also suggested that an adequate amniotic fluid volume is needed in the latency period to prolong pregnancy. In 1 negative study, there was no increase in birth weight or gestational age at delivery following transabdominal amnioinfusion because the pPROM-delivery interval was not significantly prolonged. However, most studies have observed increased birth weight and gestational age at delivery, and decreased perinatal morbidity and mortality as a consequence of a prolonged pPROM-delivery interval and prolonged pregnancy after amnioinfusion. This prospective randomized controlled study assessed the effect of transabdominal amnioinfusion on maternal and neonatal outcomes among women with pPROM during singleton live pregnancy—between 26 and 33 + 6 weeks who had an amniotic fluid index (AFI) less than the fifth percentile. The study was conducted in India between 2005 and 2007. All women in the study group were treated with transabdominal amnioinfusion at admission. After this initial treatment, the AFI was measured at weekly intervals, and the procedure was repeated when the AFI fell below the fifth percentile. The participants included 60 women who were randomized to the study group (n = 30) or the control group (n = 30). Women in the control group received expectant management. There was no statistically significant difference between the groups in the mean interval from pPROM to delivery (study group: 7.27 ± 7.53 days vs. control group: 6.70 ± 5.93 days, P = 0.75). Several adverse neonatal outcomes, however, were significantly reduced in comparison with the control group (fetal distress: 10% vs. 37%; early neonatal sepsis: 17% vs. 63%; and neonatal mortality: 17% vs. 63%), and maternal outcomes were also improved (including a higher rate of spontaneous delivery: 83% vs. 53%; and reduced postpartum sepsis: 7% vs. 33%). These findings show that transabdominal amnioinfusion does not increase the pPROM to delivery interval. However, it may increase the proportion of women with pPROM who deliver spontaneously. The investigators believe that the procedure appears to be a safe and simple intervention—with no apparent maternal or fetal risks—that potentially improves maternal and neonatal outcomes.

Mannose-Binding Lectin Gene Polymorphism and Early Neonatal Outcome in Preterm Infants

Background: Mannose-binding lectin (MBL) as a component of innate immunity plays an important role in preterm infants in whom adaptive immunity is not sufficiently developed. Polymorphisms in immunoregulatory genes influence the response to infection and subsequent inflammation. Infection and inflammation have been implicated in the mechanisms responsible for many of the diseases in the preterm newborns. Objectives: The aim of the study was to investigate the relationship between MBL gene polymorphism and early neonatal outcome in preterm infants. Methods: Codon 54 and 57 polymorphisms in MBL2 gene were genotyped in 99 preterm infants admitted to the Neonatal Intensive Care Unit at Ege University Children’s Hospital. Results: Overall frequencies of sepsis and early-onset sepsis were higher in the group of infants with MBL polymorphism when compared to infants with wild-type MBL genotype (p = 0.008, 0.009, respectively). Maximum Tollner sepsis score in the first 3 days of life was higher for the infants with variant MBL genotype (p = 0.0278). More infants in the variant MBL group had significant patent ductus arteriosus when compared to infants with wild-type MBL (27.8 vs. 9.5% respectively, p = 0.037). Conclusion: MBL gene polymorphism was associated with increased frequency of clinical sepsis particularly with early neonatal sepsis and also with higher Tollner sepsis scores and increased frequency of patent ductus arteriosus in infants. Overall mortality and incidence of culture proven sepsis, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia and necrotizing enterocolitis were not found to be related to MBL genotype.

Utility of hematologic and volume, conductivity, and scatter parameters from umbilical cord blood in predicting chorioamnionitis

We evaluated the utility of routine hematologic parameters and volume, conductivity, and scatter (VCS) parameters from umbilical cord blood in predicting pathologically confirmed chorioamnionitis. Chorioamnionitis is strongly associated with early neonatal sepsis and is the major in utero source of infectious exposure. We prospectively identified mothers who had placenta submitted for pathology and subsequently identified corresponding neonate cord blood sent for routine blood typing (n = 99). Cord blood was then sent for routine complete blood count with differential (CBCD). Among the same neonates, we retrospectively identified those who had peripheral blood sent for CBCD. We collected VCS parameter data, which are used in determining an automated leukocyte differential, from our hematology analyzer. Routine hematologic as well as VCS parameters from both cord and peripheral blood were then evaluated for predicting pathologically confirmed chorioamnionitis. In the study population, the absolute neutrophil count, neutrophil differential, mean neutrophil conductivity, and neutrophil conductivity standard deviation (SD) from cord blood showed the best predictive ability for chorioamnionitis. Among neonates with intrapartum antibiotic prophylaxis exposure, the band differential, immature neutrophil precursor differential, and neutrophil conductivity SD showed the best predictive ability. Lastly, among the neonates who had peripheral blood CBCD, the band differential and immature neutrophil precursor differential showed the best predictive ability. Overall, the peripheral blood band differential and immature neutrophil precursor differential showed better specificity and positive predictive value for chorioamnionitis than the cord blood parameters. However, the cord blood absolute neutrophil count, neutrophil differential, and mean neutrophil conductivity showed better negative predictive value. Cord blood can be a valuable source of diagnostic laboratory testing for neonates because of their small blood volume. This is the first study demonstrating that routine hematologic and VCS parameters from cord blood can be used to predict pathologically confirmed chorioamnionitis.

Transabdominal amnioinfusion in preterm premature rupture of membranes

Objective To evaluate the effect of transabdominal amnioinfusion on prolongation of pregnancy, and maternal and neonatal outcomes in preterm premature rupture of membranes (pPROM). Methods We conducted a prospective randomized controlled study of women with pPROM during singleton live pregnancy—between 26 and 33 + 6 weeks—whose amniotic fluid index (AFI) was less than the 5th percentile. The study group underwent transabdominal amnioinfusion at admission and then weekly if their AFI fell below the 5th percentile again. The control group received expectant management. Results The difference in the mean interval from pPROM to delivery between the groups was not statistically significant. Neonatal and maternal outcomes were significantly improved in the study group compared with the control group (fetal distress [10% vs 37%]; early neonatal sepsis [17% vs 63%]; neonatal mortality [17% vs 63%]; spontaneous delivery [83% vs 53%]; and postpartum sepsis [7% vs 33%]). Conclusion Transabdominal amnioinfusion reduced fetal distress, early neonatal sepsis, and neonatal mortality. In the study group, more participants delivered spontaneously and there were fewer cases of postpartum sepsis, although the pPROM–delivery interval was not increased.

440: The effect of ruptured membranes on early neonatal sepsis

440: The effect of ruptured membranes on early neonatal sepsis

Colonização materna e neonatal por estreptococo do grupo B em situações de ruptura pré-termo de membranas e no trabalho de parto prematuro

To identify the prevalence and risk factors of maternal colonization by group B streptococcus (GBS) in pregnant women with premature labor (PL) and/or premature membrane rupture (PMR). Two anal and two vaginal swabs were collected from 203 pregnant women with diagnosis of PL or PMR assisted at the practice along one year. Pregnant women with imminent labor at admission were excluded. One swab of each source was placed in a transfer milieu and sent for culture in blood-agar plates; the two remaining swabs were incubated for 24 hours in Todd-Hewitt milieu for further sowing in blood-agar plates. Risk factors were analyzed by the chi-square test, Student's t-test (p-value set at 0.05 and 95% confidence interval) and logistic regression. The following variables were analyzed: age, race, parity and mother schooling; culture results by source and type of culture; admission diagnosis; gestational age at admission; asymptomatic bacteriuria; gestational age at delivery; type of delivery; neonatal GBS colonization rate and immediate neonatal condition. Prevalence of maternal GBS colonization was 27.6% (56 cases). The colonization rates according to gestational complications were 30% for PMR, 25.2% for PL and 17.8% for PL + PMR. Univariate analysis has shown that the variables Caucasian race, low level of schooling and bacteriuria were associated with higher colonization rates. Multivariate analysis showed that the presence of urinary infection was the only variable associated with maternal colonization. The GBS detection rate was significantly higher with the use of a selective milieu and collection from both anal and vaginal sources. The neonatal colonization rate was 3.1%. Two cases of early sepsis by GBS occurred in the sample, with prevalence of 10.8 cases per one thousand live births and 50% mortality rate. The studied sample showed high maternal colonization rates by Streptococcus agalactiae. To increase GBS detection rate, it is necessary to use a selective culture milieu and to combine anal-rectal and vaginal cultures. There was a high incidence of early neonatal sepsis.

Neonatal Sepsis: A 6-Year Analysis in a Neonatal Care Unit in Taiwan

Neonatal sepsis is the most serious problem in neonatal intensive care, resulting in significant morbidity and mortality. We evaluated the causative pathogen, drug sensitivity, hematological parameters, clinical course and mortality rate of neonatal sepsis in a Taiwanese medical center and compared our results to those of previous studies conducted in Taiwan. Neonates admitted to the neonatal intensive care unit (NICU) at National Taiwan University Hospital (NTUH) between January 2001 and December 2006 were included in this study. Patients were divided into early-onset sepsis and late-onset sepsis groups if their culture tested positive within the first 7 days of life or later, respectively. A total of 109 episodes of sepsis were identified in 100 neonates. The incidence of sepsis was 4.06% among all NICU admissions. Most neonates with early-onset sepsis were term infants, while very low birth weight (VLBW) and preterm infants accounted for the majority of cases of late-onset sepsis. In early-onset sepsis, the most common pathogens responsible included group B streptococci (GBS) (36%) and Escherichia coli (E. coli) (26%). GBS was associated with more meningitis involvement but lower incidence of mortality compared with E. coli. The most common causative microorganisms in late-onset sepsis were coagulase-negative staphylococci (CONS) (40%) and Candida (15%). The sepsis-related mortality rates were higher in early-onset sepsis (10%) than in late-onset sepsis (7%). Unlike previous reports from Taiwan, in the present study, GBS was found to be the leading pathogen in early-onset sepsis. GBS screening and intrapartum antibiotic prophylaxis guidelines should be used in Taiwan to prevent early neonatal sepsis. The most common causative microorganisms of late-onset sepsis were CONS and Candida species. Candida parapsilosis was associated with a high mortality rate.

Clinical features of neonatal sepsis caused by resistant Gram‐negative bacteria

Clinical features and outcomes of neonatal sepsis caused by resistant Gram-negative bacteria are not well described in Jordan. The aim of the present study was therefore to describe microbiology and clinical features, laboratory findings and outcomes of early- and late-onset Gram-negative neonatal sepsis. All patients with Gram-negative bacteremia between July 2003 and June 2005 were retrospectively included. Resistance profiles, clinical features and outcomes of early and late-onset neonatal sepsis were compared. A total of 79 patients (after excluding all nine cases of Gram-positive bloodstream infection (BSI) were identified as having Gram-negative BSI (25 had early-onset and 54 had late-onset neonatal sepsis). Respiratory distress, metabolic acidosis and requirement of ventilation were found in 74.7%, 40.5%, and 58.2%, respectively. Hypotension was found in 22.9% of patients. Klebsiella pneumoniae was responsible for 43 cases (54.4.2%). Klebsiella pneumoniae resistance rates to ampicillin and ceftazidime were 100% and 50%, respectively. Mortality rate was 30.9%. Forty-eight percent of deaths occurred within 3 days of sepsis. Meningitis was diagnosed in five cases. Elevated C-reactive protein (CRP) and thrombocytopenia were seen in 28% and 24% of infants with early-onset sepsis, respectively, and in 79.6%, 59.3% of infants with late-onset sepsis respectively. Both early- and late-onset neonatal sepsis are caused by highly resistant Gram-negative bacteria. Mortality of sepsis is high. Elevated CRP and thrombocytopenia is seen more commonly in late-onset neonatal sepsis.

Evaluation of Cefotaxime and Desacetylcefotaxime Concentrations in Cord Blood after Intrapartum Prophylaxis with Cefotaxime

Preterm premature rupture of the membranes is associated with a high risk of neonatal sepsis. An increase in the incidence of early-onset neonatal sepsis due to ampicillin-resistant Escherichia coli in premature infants has been observed in the past few years. Intrapartum prophylaxis with ampicillin has proven to be efficient for the prevention of early neonatal sepsis due to group B streptococci. To date, there is no strategy for the prevention of early neonatal sepsis due to ampicillin-resistant E. coli. Our aim was to investigate whether a standardized dosage regimen of intrapartum cefotaxime could provide concentrations in the cord blood greater than the cefotaxime MIC(90) for E. coli. Seven pregnant women hospitalized with preterm premature rupture of the membranes and colonized with ampicillin-resistant isolates of the family Enterobacteriaceae were included. Cefotaxime was given intravenously during delivery, as follows: 2 g at the onset of labor and then 1 g every 4 h until delivery. Blood specimens were collected from the mother 30 min after the first injection and just before the second injection, and at birth, blood specimens were simultaneously collected from the mother and the umbilical cord. The concentrations of cefotaxime in the cord blood ranged from 0.5 to 8.5 mg/liter. The MIC(90) of cefotaxime for E. coli strains (0.125 mg/liter) was achieved in all cases. This preliminary study supports the use of cefotaxime for intrapartum prophylaxis in women colonized with ampicillin-resistant isolates of Enterobacteriaceae. The effectiveness of this regimen for the prevention of neonatal sepsis needs to be evaluated with a larger population.

Reliability of procalcitonin in neonatology. Experience in 59 preterm newborns

Procalcitonin (PCT) has been proposed as an interesting marker in the diagnosis, prognosis, and response to treatment of patient with neonatal sepsis. Fifty-nine neonates (34 males and 25 females) with a mean gestational age of ∼31 weeks and a mean weight of about 1750 g admitted in the Neonatal Intensive Care Unit of Cagliari (Italy) were evaluated in controls and in infected neonates, before and after 48 h of life. From our experience it emerges that PCT is a marker of early and late neonatal sepsis which is reliable in preterm neonates. A cut-off of 0.5 ng/ml starting from the third day of life appears to be capable of ensuring good test sensitivity and specificity.

Streptococcus vestibularis bacteremia following dental extraction in a patient on long-term hemodialysis: a case report.

Sir, Streptococcus vestibularis is a normal inhabitant of vestibules of the human oral cavity, and it has rarely been associated with human disease except that two cases of infectious endocarditis of the prosthetic valve [1,2], early neonatal sepsis and bacteremia in both cancer and rheumatic valve disease patients [3–5]. A 24-year-old woman, a known case of end-stage renal disease on haemodialysis was admitted with severe toothache, fever and malaise for a 2-week duration. Dental caries of the upper second molar were found by an expert dental surgeon, the carious tooth was removed and the pain was relieved. However, she developed fever and malaise again 2 days following tooth extraction. She had no symptoms of infection of the upper or lower respiratory, gastrointestinal or genitourinary systems. On physical examination her temperature was 38°C, heart rate was 92 bpm and blood pressure was 130/ 80 mmHg. Her oral hygiene was very poor. Cardiovascular system examination showed a grade 2/6 functional ejection systolic murmur at the lower left sternal edge. There were no clinical findings specific to bacterial endocarditis, either clinically or radiologically. (A trans-esophageal echocardiogram was done to rule out infective endocarditis.) Her leukocyte count was 11 900 cells/L (92% neutrophils), CRP 55 mg/L and ESR 54 mm/h. We thought that the subclavian catheter (inserted because of a–v fistula disfunction) could have been infected but there were no exit-site features of infection. Vancomycin (1 g iv, three times a week, post-HD) was started immediately. Her temperature returned to normal 48 h later. The patient had no complaints of malaise 3 days later. Two blood cultures grew gram-positive cocci. Subcultures grown on solid media showed S. vestibularis by identification kits (BBL Crystal Gram-Positive Identification Kits®). The microorganism was susceptible to vancomycin. Two other blood cultures were taken on the 10th day of vancomycin therapy and they were negative. The patient remained on vancomycin therapy for 18 days, with neither fever nor malaise. On the 18th day the patient's leukocyte count was 6900 cells (72% neutrophils), CRP was 5 mg/L and ESR was 21 mm/h. We stopped vancomycin therapy, and the patient was discharged. Haemodialysis patients are liable to develop blood stream infections following surgical or dental procedures. To our knowledge, ours is the first case of bacteremia caused by S. vestibularis in a haemodialysis patient. We chose vancomycin for treatment as it was shown to be susceptible to vancomycin elsewhere [5]. There is no recommendation for the duration of antibiotic therapy in the literature. We continued the treatment for 3 weeks and stopped therapy after blood cultures were negative. We suggest that in patients with poor dental hygiene and history of orodental surgery, virulent streptococci should be considered. Conflict of interest statement. None declared.

Factors associated with umbilical artery acidemia in term infants with low Apgar scores at 5 min

Objective To evaluate predictors of umbilical artery acidemia in term neonates with low Apgar score. Study design From a cohort of term singleton deliveries over a 13-year period, we selected neonates with 5-min Apgar score <7. Acidemia was defined as umbilical artery pH < 7.00 or base excess (BE) ≤−12 mmol/L. Three pathogenic processes of neonatal acidemia were evaluated: (1) intrauterine vascular disease, defined as preeclampsia, clinical diagnosis of placental abruption, birth weight <10th centile, or histologic evidence of placental infarction or severe vascular pathology, (2) intrauterine infection, defined as clinical chorioamnionitis, histologic chorioamnionitis, or early neonatal sepsis, and (3) acute intrapartum events, which included cases of cord prolapse, amniotic fluid embolism, uterine rupture, sudden and sustained fetal bradycardia or absence of FHR variability with a previously normal pattern, shoulder dystocia or complicated breech extraction. The associations of such processes with umbilical artery evidence of acidemia were tested using χ 2, Fisher's exact test, Student's t-test, and logistic regression, with P < 0.05 or odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. Results Among the 27,395 neonates in the cohort, an Apgar score at 5 min <7 was recorded in 94 (0.32%) and it was associated with umbilical artery acidemia in 33 cases. Logistic regression analysis showed that intrauterine vascular disease was independently associated with umbilical cord acidemia ( P = 0.035, OR = 3.2, 95% CI = 1.1–9.7) whereas intrauterine infection (OR = 1.1, 95% CI 0.4–3.4) and acute intrapartum events (OR = 2.1 95% CI 0.6–7.0) were not. Conclusions Umbilical artery evidence of acidemia is present in 38% of term babies with low Apgar score and it is predominantly associated with chronic antepartum vascular disease. Neither intrauterine infection nor acute intrapartum events are significantly associated with umbilical artery acidemia.