Incidence Of Neonatal Sepsis Research Articles

Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections.

Chorioamnionitis is more likely to occur when meconium-stained amniotic fluid (MSAF) is present. Meconium may enhance the growth of bacteria in amniotic fluid by serving as a growth factor, inhibiting bacteriostatic properties of amniotic fluid. Many adverse neonatal outcomes related to MSAF result from meconium aspiration syndrome (MAS). MSAF is associated with both maternal and newborn infections. Antibiotics may be an effective option to reduce such morbidity. The objective of this review is to assess the efficacy and side effects of prophylactic antibiotics for MSAF during labour in preventing maternal and neonatal infections. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014). Randomised controlled trials (RCTs) comparing prophylactic antibiotics with placebo or no treatment during labour for women with MSAF. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We included two studies with 362 pregnant women. Both studies compared ampicillin-sulbactam (N = 183) versus normal saline (N = 179) in pregnant women with MSAF. Prophylactic antibiotics appeared to have no statistically significant reduction in the incidence of neonatal sepsis (risk ratio (RR) 1.00, 95% CI 0.21 to 4.76), neonatal intensive care unit (NICU) admission (RR 0.83, 95% CI 0.39 to 1.78) and postpartum endometritis (RR 0.50, 95% CI 0.18 to 1.38). However, there was a significant decrease in the risk of chorioamnionitis (RR 0.36, 95% CI 0.21 to 0.62). No serious adverse effects were reported. Drug resistance, duration of mechanical ventilation and duration of admission to NICU/hospital were not reported. Most of the domains for risk of bias were at low risk of bias for one study and at unclear risk of bias for the other study. The quality of the evidence using GRADE was low for neonatal sepsis, postpartum endometritis, and neonatal mortality and morbidity prior to discharge (Neonatal intensive care admissions) and of moderate quality for chorioamnionitis. Current evidence indicates that compared to placebo, antibiotics for MSAF in labour may reduce chorioamnionitis. There was no evidence that antibiotics could reduce postpartum endometritis, neonatal sepsis and NICU admission. This systematic review identifies the need for more well-designed, adequately powered RCTs to assess the effect of prophylactic antibiotics in the incidence of maternal and neonatal complications.

PS-310 Immediate Delivery Versus Expectant Care In Women With Preterm Prelabour Rupture Of The Membranes Close To Term (ppromt): A Multi-centre Randomised Controlled Trial

<h3>Background</h3> Preterm prelabour rupture of membranes (PPROM) is the cause of 40% of all preterm births. Best practice for women who rupture their membranes preterm is not known. The aim of this study is to determine whether immediate delivery or expectant management of women with PPROM at 34–36⁶ weeks gestation is associated with less neonatal and/or maternal morbidity. <h3>Methods</h3> The PPROMT Trial is a large, international, multi-centre, randomised controlled trial with 1835 recruits from 65 centres in 11 countries. The primary study outcome is the incidence of neonatal sepsis. Secondary outcomes include severe neonatal morbidity/mortality (sepsis, positive pressure ventilation &gt;24 h or death), perinatal mortality, neonatal respiratory distress syndrome, mode of delivery and duration of hospitalisation for mothers and infants. <h3>Results</h3> The trial finished in December 2013, 923 women were randomised to receive early delivery and 912 expectant management. 52 (2.8%) infants had sepsis. 134 (7.3%) had severe neonatal morbidity/mortality, including 6 (0.3%) deaths and 93 (5%) ventilation &gt;24 h. 123 (6.7%) had Respiratory Distress Syndrome. 408 (22.2%) were born by caesarean section. Length of stay (median (IQR)) was 5 (4–8) days for mothers and 5 (3–9) days for infants. Analysis by intention to treat will be presented. <h3>Conclusions</h3> There is a significant rate of neonatal and maternal morbidity after maternal PPROM at 34–36⁶. If it can be demonstrated that either early planned birth or expectant management in this clinical situation is associated with less neonatal and/or maternal morbidity this will change current international practice.

PO-0518 The Incidence And The Microbial Pattern Of Neonatal Sepsis In Jordan

Introduction Neonatal sepsis is a common and potentially serious neonatal disease especially in preterm babies and more complicated in developing countries. Objectives To study the incidence and the microbial pattern of neonatal sepsis in our unit in Amman/Jordan. Method A retrospective study of all newborn cases admitted to our NICU as suspected sepsis over a 4-year period, 2001–2004 analysing the results of blood cultures. Results The total number of newborns delivered in our NICU over a 4-year period was 25715. - 819 (3.2%) babies were admitted as suspected sepsis. *616(75%) were full term babies. *203 (25%) were preterm babies (28 to 36 weeks) - The total culture- proven cases (positive blood cultures) were 51 (6.2%).out of which 21(40%) cases were preterm babies. So culture-proven sepsis was found in about 10% of preterm babies and in about 5% of full term babies who were admitted as suspected sepsis. - The overall incidence of sepsis was 2 per 1000. - Gram negative organisms recovered in 32 cases (63%),mainly Klebsiella species in 21 cases (40%), E.coli in 7(14%)and Pseudomonas in 4 cases (8%). - Gram positive cases were 19(37%) : Staphylococci aureus in 7 cases, Staph. Epidermidis in 4, GBS in 5 and Strept.viridans in 3 cases. The mortality among all culture-proven cases was 2 cases (4%). Conclusion - A bout 3.2% of all newborns were admitted as suspected sepsis. - Only 6% of suspected cases of sepsis were proven culture positive-The overall incidence of neonatal sepsis in our unit is 2/1000. - Klebsiella species is the commonest pathogen isolated in our NICU.

Recent epidemiology of neonatal sepsis in Japan: did the strategies to control and prevent MRSA transmission lead to a reduction in the incidence of late-onset sepsis?

Neonatal sepsis is a significant cause of morbidity and mortality in newborns, particularly in the preterm or low birth weight infant. In this epidemiologic review regarding neonatal sepsis, the recent epidemiology and causative pathogens in Japan are described and compared with data from international organizations. Recent Japanese multicenter studies report the incidence of neonatal sepsis at 0.74%. Although the incidence of early-onset sepsis has been low (0.13%), approximately 5% of very or extremely low birth weight infants develop late-onset sepsis with a high mortality rate. In Japan for such cases, the most predominant causative patho- gen is methicillin-resistant Staphylococcus aureus; internationally, the most commonly reported pathogen is coagulase-negative staphylococci. It is our contention that the incorporation of the strategies to control and to prevent health care-associated MRSA transmission has contributed to the reduction in the incidence of late-onset sepsis.

Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV).

The incidence of chorioamnionitis occurs in between eight and 12 women for every 1000 live births and 96% of cases of chorioamnionitis are due to ascending infection. Following spontaneous vaginal delivery, 1% to 4% of women develop postpartum endometritis. The incidence of neonatal sepsis is 0.5% to 1% of all infants born. Maternal vaginal bacteria are the main agents for these infections. It is reasonable to speculate that prevention of maternal and neonatal infections might be possible by washing the vagina and cervix with an antibacterial agent for all women during labour. Chlorhexidine belongs to the class of compounds known as the bis-biguanides. Chlorhexidine has antibacterial action against a wide range of aerobic and anaerobic bacteria, including those implicated in peripartal infections. To evaluate the effectiveness and side effects of chlorhexidine vaginal douching during labour in reducing maternal and neonatal infections (excluding group B streptococcal and HIV). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2014), reference lists of retrieved reports and journal letters and editorials. Randomized or quasi-randomized trials comparing chlorhexidine vaginal douching during labour with placebo or other vaginal disinfectant to prevent (reduce) maternal and neonatal infections (excluding group B streptococcal and HIV). Two review authors independently assessed trial eligibility and quality, extracted and interpreted the data. A third review author analyzed and interpreted the data. The fourth author also interpreted the data. We included three studies (3012 participants). There was no evidence of an effect of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. Although the data suggest a trend in reducing postpartum endometritis, the difference was not statistically significant (three trials, 3012 women, risk ratio 0.83; 95% confidence interval 0.61 to 1.13).Assessment of the quality of the evidence using GRADE indicated that the levels of evidence for all primary outcomes and one important secondary outcome were low to moderate. There is no evidence to support the use of vaginal chlorhexidine during labour in preventing maternal and neonatal infections. There is a need for a well-designed randomized controlled trial using appropriate concentration and volume of vaginal chlorhexidine irrigation solution and with adequate sample size.

C-Reactive Protein, Immature to total Neutrophil Ratio and Micro ESR in early diagnosis of Neonatal Sepsis

Neonatal Sepsis is a clinical syndrome characterized by signs and symptoms of infection, identified & confirmed by positive blood cultures. As per National Neonatal Perinatal Database (NNPD) 2002-2003, the incidence of neonatal sepsis in India was 30 per 1000 live birth.Systemic bacterial infection is known by the term neonatal sepsis which incorporates septicemia, pneumonia and meningitis. C-reactive protein (CRP), an acute phase reactant has advantages of low serum levels in normal infants, a rapid rise after 12 to 24 hours of sepsis and a massive rise thereafter as long as inflammatory stimuli persist and followed by immediate fall of serum level as soon as inflammation subside. Micro ESR can be compared to wintrobe’s method of doing ESR and can be used in neonatal sepsis. Rates do not vary considerably with gestational age, birth weight, but are inversely related to hematocrit level, Particularly when it is less than 40 mm/dl. The micro ESR is generally mildly elevated in non infectious conditions. In most of the patients with infection the micro ESR is elevated within 24 hours of infection and it is not influenced by antibiotic. It is well-known fact that understanding hematology of neonatal sepsis helps in early iden­tification of suspected cases of neonatal sepsis. Amongst Hematological parameters Immature to total neutrophil( I:T) ratio has a reasonably good predictive value for early diagnosis of neonatal septicemia. This study is done as an endeavor to add to something about our preexisting knowledge of ‘diagnosis of neonatal sepsis’ early for better management of this group of patients

Neonatal morbidities among full-term infants born to obese mothers

Introduction: Impact of maternal obesity on full-term neonates is not known.Objective: We hypothesized increased incidence of neonatal morbidities requiring NICU admission in full-term neonates of obese women compared to neonates of normal-weight women.Methods: Data from full-term pregnancies collected in the Consortium of Safe Labor study were analyzed. Maternal BMI was classified using the WHO criteria. Incidence of neonatal outcomes including sepsis, PDA, NEC, respiratory distress, or their combination were compared between newborns of obese and normal-weight women.Results: Of the 109 488 women included in the study, 17.7% were obese. Maternal co-morbidities (diabetes, gestational diabetes, hypertension, and preeclampsia) increased with increasing maternal BMI. Both maternal obesity and its related co-morbidities were associated with higher incidence of neonatal morbidities. After adjusting for maternal comorbidities, there was a higher incidence of sepsis (AOR 1.91(1.45–2.50)), and combination of any of the neonatal outcomes (AOR 1.66(1.32–2.09)) among newborns of obese women than those of normal-weight women, along with an increased trend for incidence of PDA (Cochran-Armitage Test (CA) = 23.1, p < 0.0001) and NEC (CA = 7.2, p = 0.007).Conclusion: Maternal obesity is independently associated with increased incidence of neonatal sepsis and a combination of neonatal morbidities in full-term newborns with an increased trend for PDA and NEC.

Lumbar Puncture in Neonates with Sepsis

Introduction: Infections are one of the main causes of death during childhood. Epidemiologic studies in Iran showed that the incidence of neonatal sepsis was 1.8% in 1995. Moreover, the incidence of neonatal meningitis is 0.2 to 0.4 in per 1,000 live births. The aim of this study was to determine the necessity of lumbar puncture (LP) in early neonatal sepsis. Methods: In a retrospective study, after obtaining ethical approval, we evaluated the records of 1,100 neonates, younger than 7 days, who were admitted to the hospital between 2001 and 2007. They were suspected of sepsis and thus, LP was performed. Statistical analyses were performed by SPSS version 16. Nominal variables were compared using Chi-square or Fisher’s exact test. Other parametric and non-parametric tests were used as required. Results: In our study, 1,100 neonates, suspected of sepsis, were evaluated. Of all neonates, 28.3% and 71.7% were older and younger than 3 days, respectively. Male-to-female ratio was 1:5 in 115 neonates. Sepsis was confirmed by positive blood culture, and 21 neonates (2.1%) had positive cerebrospinal fluid (CSF), which was significantly associated with blood culture results. Conclusion: There was a significant relationship between blood culture and CSF culture results. However, regarding the low incidence of positive CSF, LP should be performed for each case, based on clinical manifestations and clinical opinion.

Neonatal sepsis is mediated by maternal fever in labour epidural analgesia

The association between neonatal sepsis and labour epidural analgesia (EA) was evaluated. In a retrospective matched case–control study, 453 women delivering with EA (EA group) were matched on parity with 453 women with deliveries without EA (non-EA group). Significantly more neonates born in the EA-group had fever ≥ 38.0°C (11.6% vs 1.8%, p < 0.001) at birth. The overall incidence of neonatal sepsis, based on clinical symptoms and defined as proven (by a positive blood culture) or suspected (no positive blood culture), was significantly higher in the EA group (6.0% vs 2.2%; p = 0.002), but the incidence of proven neonatal sepsis alone was not (0.4% vs 0%; p = 0.250). EA turned out to be an independent risk factor for neonatal sepsis (adjusted OR 2.43, 95% CI 1.15–5.13; p = 0.020). However, in the EA group as well as the non-EA group, the incidence of neonatal sepsis was significantly higher in mothers with intrapartum fever compared with afebrile mothers (11.0% vs 2.9% in the EA group; p = 0.004; 8.2% vs 1.3% in the non-EA group; p = 0.006). Therefore we conclude, that the positive association between neonatal sepsis and labour EA is possibly mediated by maternal intrapartum fever.

ABSTRACT 712

Background and aims: The incidence of neonatal sepsis is reducing, especially Group B Streptococcus. We aimed to review a recent cohort of patients to ensure risk factors are identified and assess our current antimicrobial guidelines. Methods: Retrospective review of all cases identified from Regional Retrieval Team (RRT) database of those less than 12 weeks of age with a diagnosis of sepsis between 01/12/2012-30/11/2013. Results: Patients less than 12 weeks of age comprised 69 of total 1127 (6%) referrals to RRT over 12 months. 41 patients (59%) fulfilled the inclusion criteria. Patients were aged between CGA 36 weeks to 3 months. 7/41 (17%) had CGA less than 38/40 at time of admission and 12/41 (29%) patients were ex preterm. 30/41 (73%) had positive culture results (Table 1) with highest incidence group B streptococcal sepsis. Of these 9 patients, in only 2 cases had maternal group B streptococcus previously been confirmed. In total, 19/41 (46%) had a recognised risk factor for sepsis. All but 2 patients survived to discharge home.Table: No title available.Conclusions: Neonatal sepsis represents a small but significant proportion of RRT workload. Initial presentation and observations may be falsely reassuring. Early recognition of sepsis and appropriate antibiotic therapy is essential. In certain cases, despite best therapies, outcome may be poor.

Economic analysis comparing induction of labor and expectant management in women with preterm prelabor rupture of membranes between 34 and 37 weeks (PPROMEXIL trial)

To compare the costs of induction of labor and expectant management in women with preterm prelabor rupture of membranes (PPROM). Economic analysis based on a randomized clinical trial. Obstetric departments of eight academic and 52 non-academic hospitals in the Netherlands. Women with PPROM near term who were not in labor 24h after PPROM. A cost-minimization analysis was done from a health care provider perspective, using a bottom-up approach to estimate resource utilization, valued with unit-costs reflecting actual costs. Primary health outcome was the incidence of neonatal sepsis. Direct medical costs were estimated from start of randomization to hospital discharge of mother and child. Induction of labor did not significantly reduce the probability of neonatal sepsis [2.6% vs. 4.1%, relative risk 0.64 (95% confidence interval 0.25-1.6)]. Mean costs per woman were €8094 for induction and €7340 for expectant management (difference €754; 95% confidence interval -335 to 1802). This difference predominantly originated in the postpartum period, where the mean costs were €5669 for induction vs. €4801 for expectant management. Delivery costs were higher in women allocated to induction than in women allocated to expectant management (€1777 vs. €1153 per woman). Antepartum costs in the expectant management group were higher because of longer antepartum maternal stays in hospital. In women with pregnancies complicated by PPROM near term, induction of labor does not reduce neonatal sepsis, whereas costs associated with this strategy are probably higher.

Neonatal sepsis: A risk approach

Background: Neonatal sepsis continues to be a major cause of neonatal mortality in India. Incidence of neonatal sepsis in India was 30/1000 live births and is not changed much over the past decade. Aims and Objectives: The present study was intended to know the incidence and mortality rates of neonatal sepsis among hospital admission, whether there is any change in the risk factors over a decade and to evolve a risk approach in the management of neonatal sepsis. Patients and Methods: This was a cross-sectional study in a tertiary care teaching hospital. One hundred and twenty neonates with confirmed sepsis were enrolled. Cases were divided into early onset sepsis (EOS) (presenting in the first 72 h) and late onset sepsis (LOS) (presenting after 72 h). Information regarding risk factors was collected by questionnaire. All cases were started on ampicillin and gentamycin later upgraded based on culture and sensitivity. Cases were followed-up to discharge/death and the risk factors associated with fatal sepsis were analyzed using Chi-square test. Results: During 2003-2004, the incidence of sepsis was 6.04% of total pediatric admissions with EOS and LOS 3.08% and 2.96%. The same in 2013-2014 were 6.03%, 2.57% and 3.44%, respectively. Highly significant risk factors were inadequate antenatal care, assisted vaginal delivery, and premature rupture of membranes, low birth weight and associated complications. Klebsiella, Staphylococcus aureus and Escherichia coli were the most common organisms in both EOS and LOS. Conclusion: Overall incidence of sepsis and EOS is not changed much but the incidence of LOS has increased from 2.94% to 3.44%.

Assessment of the Incidence of Neonatal Sepsis, its Risk Factors, Antimicrobials Use and Clinical Outcomes in Bishoftu General Hospital, Neonatal Intensive Care Unit, Debrezeit-Ethiopia

Background: The incidence of neonatal sepsis (NS) varies from 6 to 9 cases per 1,000 live births, but is higher among low-birth-weight neonates. The purpose of the present study was to examine the risk factors, antimicrobial use pattern and clinical outcomes of NS. Methods: A prospective cross-sectional study was conducted using pretested and validated checklists. Results: Among the total 306 neonates 249(81.4%) were age less than or equal to 7days, and 169(55.23%) were male, while 251(82%) were attended antenatal care, 136 (44.44%) were low in birth weight ( 12000/mm3. Two hundred twenty one (72.2%) of the neonates were receive antibiotics for management of sepsis while 74 (24.2%) were receive antibiotics for other managements. The most frequently prescribed antibiotic was the combination of ‘ampicillin + gentamicin’ with 67(21.9%) followed by single antibiotic prescriptions of benzyl penicillin 33(10.8%) and cloxacillin 8(2.6%). A significant number of neonates (p=0.000) with 95% C.I of (1.934-8.967) were born in health center and developed sepsis. This value is 4.2 times higher when compared to the neonates born in home. A significant number of neonates born with the aid of instrument in hospitals were also developed sepsis (p=0.26). The risk of acquiring sepsis in neonates born with the aid of instruments was 6.2 times higher than children born vaginally in natural way. A significant number of neonates born from mothers’ with urinary tract infection (UTI) developed sepsis (p=0.02) and this figure was 2.9 times higher than neonates born from mothers’ with no UTI. Conclusions: In the present study, the most common risk factors for the incidence of neonatal sepsis were place of delivery, mode of delivery and mothers with UTI.

Assessment of the incidence of neonatal sepsis, its risk factors, antimicrobials use and clinical outcomes in Bishoftu general hospital, neonatal intensive care unit, Debrezeit-Ethiopia.

Background: The incidence of neonatal sepsis (NS) varies from 6 to 9 cases per 1000 live births, but is higher among low-birth-weight neonates. Therefore, the purpose of this study was to examine the risk factors, antimicrobial use pattern and clinical outcomes of NS at Bishoftu General Hospital, neonatal intensive care unit, Debrezeit-Ethiopia. Methods: A prospective cross-sectional study was conducted using pretested and validated checklists. Results: Among the total 306 neonates (0-28 days of age) recruited, 249 (81.4%) were age ≤7 days, 169 (55.23%) were male, 251 (82%) were attended antenatal care, 136 (44.44%) were low in birth weight (≤2.5 kg) and 155 (50.7%) had total of white blood cell count ≥12000/mm 3 . 221 (72.2%) of the neonates diagnosed as sepsis received antibiotics while 74 (24.2%) received antibiotics for other diagnosis. The most frequently prescribed antibiotic was the combination of ‘ampicillin + gentamicin’ prescription 67 (21.9%) followed by the single antibiotic prescriptions of benzyl penicillin 33 (10.8%) and cloxacillin 8 (2.6%). A significant number of neonates ( p = 0.000) with 95% confidence interval of (1.934-8.967) were born in health center and developed sepsis. This value is 4.2 times higher when compared with the neonates born in the home. A significant number of neonates using instrument in hospitals were also developed sepsis ( p = 0.26). The risk of acquiring sepsis in neonates born using instrument was almost 6.2 times more common than children born vaginal in the natural way. A significant number of neonates born from mothers’ with urinary tract infections (UTI) developed sepsis ( p = 0.02) and this figure was almost 2.9 times higher compared to neonates born from mothers’ with no UTI diagnosis. Conclusions: In the present study, the most common risk factors were identified and place of delivery, mode of delivery and mother with UTI during delivery were the most common risk factors for the incidence of NS.

Early and Late Onset Neonatal Sepsis in Very Low Birth Weight Infants in a Tertiary Center in Saudi Arabia

Background: Incidences and causative organisms of neonatal sepsis in the developing countries are underreported. The aim of the study was to determine the overall incidence of neonatal sepsis in very low birth weight (VLBW) infants born at one of university hospitals in Riyadh, Saudi Arabia for the period 1999 to 2007, and identify the incidences and commonest isolated pathogens in both early and late onset episodes of sepsis in this group of infants. Methods: A retrospective study of all very low birth weight (500grams to 1500 grams) infants born at King Khalid University Hospital (KKUH) in Riyadh over a 9-year period from January 1999 to December 2007 were included. Data were collected from medical records and NICU database after obtaining ethics approval. All cultures were taken (blood and/or CSF) prior to initiation of antibiotics. Only first episodes of sepsis were considered in this study. The main outcomes are total incidences of sepsis, incidence of early and late onset sepsis, and the causative pathogens for each type of sepsis. Results: 48% of included infants (225/468) had positive blood cultures. The incidence of early onset sepsis (EOS) was 10.9% and of late onset sepsis (LOS) was 37.1%. Gram positive pathogens were the commonest causative organisms in both early and late onset sepsis (74.5% and 87.4% respectively). Staphylococcus epidermis was the commonest single pathogen isolated in both groups (45% in EOS, and 63.8% in LOS). Conclusion: The rate of neonatal sepsis in VLBW infants was high (48%) with high rates of EOS as well as LOS which necessitates a high priority to prevent and control sepsis in our unit.

Neonatal Sepsis: An Update

Sepsis is the most common cause of neonatal mortality. As per National Neonatal-Perinatal Database (NNPD), 2002-2003, the incidence of neonatal sepsis in India was 30 per 1000 live births. Signs and symptoms of sepsis are nonspecific; therefore empirical antimicrobial therapy is promptly initiated after obtaining appropriate cultures. The early manifestations of neonatal sepsis are vague and ill-defined. Novel approaches in the diagnosis of neonatal sepsis include heart rate analysis on ECG, and colorimetric analysis of skin color. Although blood culture is the gold standard for the diagnosis of sepsis, culture reports are available only after 48-72 hours. In this era of multidrug resistance, it is mandatory to avoid unnecessary use of antibiotics to treat non-infected infants. Thus, rapid diagnostic test(s) that include Interleukien-6 (IL-6), neutrophil CD64 index, procalcitonin and nucleated RBC count– and differentiate the infected infants from the non-infected, particularly in the early neonatal period– have the potential to make a significant impact on neonatal care. The aim of this review is to specify the diagnostic criteria, treatment guidelines, and a summary of recent diagnostic tests of sepsis, along with the preventive measures.

712: Behavioral and developmental outcome of neonates at 2 years of age after preterm prelabor rupture of membranes: follow up of the PPROMEXIL trial

We recently found that induction of labor (IoL) did not reduce the incidence of neonatal sepsis in women with preterm prelabor rupture of membranes (PPROM) between 34 and 37 weeks’ gestation.1,2 In this abstract, we report the neurodevelopmental and behavioral follow-up of these children at 2 years of age.

Intravenous Immunoglobulin in Neonatal Sepsis

Neonatal sepsis remains the major cause of mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay in newborn infants. Despite of advances in technology and optimal antibiotic treatment, incidence of neonatal sepsis and its complications remains unacceptably high especially in developing countries. Premature neonates in particular are at higher risk due to developmentally immature host defense mechanisms. Though not approved by Food and Drug Administration (FDA) U.S.A, off label use of intravenous immunoglobulin continues in many countries. Recent evidences showed no significant decrease in the mortality rate or other outcomes when intravenous immunoglobulin is administered in addition to standard therapies. Hence, use of intravenous immunoglobulin in suspected or proven neonatal sepsis is not recommended. The expense of prophylactic use of intravenous immunoglobulin administration for both term and preterm newborn population, given the minimal benefit is not justified. Future studies are required which should focus on other prophylactic or adjuvant treatment modalities in addition to the standard therapy in neonatal sepsis. DOI: http://dx.doi.org/10.3126/jnps.v33i2.7400 J Nepal Paediatr Soc. 2013; 33(2):125-128

Different corticosteroids and regimens for accelerating fetal lung maturation for women at risk of preterm birth

Despite the widespread use of antenatal corticosteroids to prevent respiratory distress syndrome in preterm infants, there is currently no consensus as to the type of corticosteroid to use; nor the dose, frequency, timing of use or the route of administration. To assess the effects of different corticosteroid regimens for women at risk of preterm birth. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013). All identified published and unpublished randomised controlled trials or quasi-randomised control trials comparing any two corticosteroids (dexamethasone or betamethasone or any other corticosteroid that can cross the placenta), comparing different dose regimens (including frequency and timing of administration) in women at risk of preterm birth were included. We planned to exclude cross-over trials and cluster-randomised trials. We included studies published as abstracts only along with studies published as full-text manuscripts Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. For this update, 12 trials (1557 women and 1661 infants) were included. Dexamethasone was associated with a reduced risk of intraventricular haemorrhage (IVH) compared with betamethasone (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.21 to 0.92; four trials, 549 infants). No statistically significant differences were seen for other primary outcomes: respiratory distress syndrome (RDS) (RR 1.06, 95% CI 0.88 to 1.27; five trials, 753 infants) and perinatal death (neonatal death RR 1.41, 95% CI 0.54 to 3.67; four trials, 596 infants). Similarly, very few differences were seen for secondary outcomes such as rate of admission to the neonatal intensive care unit (NICU) although in one trial, those infants exposed to dexamethasone, compared with betamethasone, had a significantly shorter length of NICU admission (mean difference (MD) -0.91 days, 95% CI -1.77 to -0.05; 70 infants). Results for biophysical parameters were inconsistent, but mostly no clinically important differences were seen.Compared with intramuscular dexamethasone, oral dexamethasone significantly increased the incidence of neonatal sepsis (RR 8.48, 95% CI 1.11 to 64.93) in one trial of 183 infants. No statistically significant differences were seen for other outcomes reported.Apart from a reduced maternal postpartum length of stay for women who received betamethasone at 12-hourly intervals compared to 24-hourly intervals in one trial (MD -0.73 days, 95% CI -1.28 to -0.18; 215 women), no differences in maternal or neonatal outcomes were seen between the different betamethasone dosing intervals assessed. Similarly, no significant differences in outcomes were seen when betamethasone acetate and phosphate was compared with betamethasone phosphate in one trial. It remains unclear whether one corticosteroid (or one particular regimen) has advantages over another.Dexamethasone may have some benefits compared with betamethasone such as less IVH, and a shorter length of stay in the NICU. The intramuscular route may have advantages over the oral route for dexamethasone, as identified in one small trial. Apart from the suggestion that 12-hour dosing may be as effective as 24-hour dosing of betamethasone based on one small trial, few other conclusions about optimal antenatal corticosteroid regimens were able to be made. No long-term results were available except for a small subgroup of 18 month old children in one trial. Trials comparing the commonly used corticosteroids are most urgently needed, as are trials of dosages and other variations in treatment regimens.

Quality in practice: preventing and managing neonatal sepsis in Nicaragua

Incorrect and excessive diagnosis of newborn infections in Nicaragua caused overcrowding in the neonatal intensive care units and unnecessary hospitalization. A baseline study in nine hospitals found that none correctly utilized disinfectants, sterilization or hand hygiene and that diagnosis of neonatal sepsis was based primarily on clinical manifestations. In 2007, the Ministry of Health (MINSA), with Unites States Agency for the International Development technical assistance, began developing guidelines and implementing quality improvement in infection prevention and control to reduce neonatal infections. In a second intervention phase, the MINSA introduced an algorithm for correct identification of maternal risk factors and standardized laboratory tests for neonatal sepsis. Interventions included developing national guidelines on correct use of disinfectants and hand hygiene; training medical staff on the guidelines; revising the basic medical supply list to support appropriate antisepsis; defining a package of diagnostic tests for neonatal sepsis and systematically measuring compliance with the new procedures. The 18 hospitals achieved appropriate use of disinfectants in a 12-month period. In seven hospitals that introduced improvements in diagnosis and management of neonatal sepsis, application of the standardized laboratory package in suspected sepsis cases increased from 0% in April 2009 to 93% in July 2011, and the median incidence of neonatal sepsis was reduced by 67%. The organizational changes implemented for the diagnosis and verification of neonatal sepsis led to a reduction in the newborn sepsis admissions and expenditures for antibiotics, allowing resources to be redirected to treating other critically ill newborns.