Level Neonatal Intensive Care Unit Research Articles

Efficacy of antimicrobial-impregnated catheters in preventing sepsis post epicutaneo-caval catheter (ECC) removal in neonates: A retrospective study.

Epicutaneo-caval catheters (ECC) are vital in neonatal intensive care units (NICU) in enabling prolonged venous access. Despite their benefits, central line-associated bloodstream infections (CLABSI) pose a potential risk. The ECC removal procedure may contribute to an increased risk of post removal sepsis through biofilm release. Antimicrobial-impregnated ECCs have been proposed as a potential solution to prevent this complication, but research on their effectiveness in neonates is limited. To compare post-ECC or neonatal peripherally inserted central catheter (n-PICCs) removal sepsis rates when using conventional or antimicrobial-impregnated catheters in neonates. A retrospective, single center cohort analysis using 2019 data from 421 neonates after successful ECC insertion at the Women's Wellness and Research Center, a large tertiary level NICU in Qatar. The study systematically collected data on demographics, insertion, and removal as well as microbiology, and infection data. Statistical analyses compared conventional and antimicrobial ECCs, with a focus on the incidence of sepsis within 72 hr post-removal. After excluding non-eligible, 349 cases were included in the analysis (138 conventional, 211 antimicrobial-impregnated). There were no significant demographic differences between the two groups. The CLABSI incidence was higher amongst the antimicrobial ECC group (4% vs 0.6%, p = 0.031). Among the included neonates, the confirmed post-removal sepsis incidence was 4.3% (6 cases) for the conventional and 10% (21 cases) for the antimicrobial ECC groups, which was not statistically significant (p = 0.055). The study noted a higher, but statistically insignificant, incidence of post removal sepsis when using antimicrobial-impregnated ECCs. This finding raises questions about the effectiveness of antimicrobial ECCs in preventing post-removal sepsis in this patient population. Further randomized trials are needed to assess the role of antimicrobial ECCs amongst neonates and to refine neonatal ECC care strategies.

Resource and Service Use after Discharge Among Infants 22-25 Weeks Estimated Gestational Age at the First High-Risk Infant Follow-Up Visit in California

To examine resource and service use after discharge among infants born extraordinarily preterm in California who attended high-risk infant follow-up (HRIF) clinic by 12months corrected age. We included infants born 2010-2017 between 22+0/7 and 25+6/7weeks' gestational age in the California Perinatal Quality Care Collaborative and California Perinatal Quality Care Collaborative-California Children's Services HRIF databases. We evaluated rates of hospitalization, surgeries, medications, equipment, medical service and special service use, and referrals. We examined factors associated with receiving ≥ 2 medical services, and ≥ 1 special service. A total of 3941 of 5284 infants received a HRIF visit by 12months corrected age. Infants born at earlier gestational ages used more medications, equipment, medical services, and special services and had higher rates of referral to medical and special services at the first HRIF visit. Infants with major morbidity, surgery, caregiver concerns, and mothers with more years of education had higher odds of receiving ≥ 2 medical services. Infants with Black maternal race, younger maternal age, female sex, and discharge from lower level neonatal intensive care units (NICUs) had lower odds of receiving ≥ 2 medical services. Infants with more educated mothers, multiple gestation, major morbidity, surgery, caregiver concerns, and discharge from lower level NICUs had increased odds of receiving a special service. Infants born extraordinarily preterm have substantial resource use after discharge. High resource utilization was associated with maternal/sociodemographic factors and expected clinical factors. Early functional and service use information is valuable to parents and underscores the need for NICU providers to appropriately prepare and refer families.

Morbidity and trends in length of hospitalisation of very and extremely preterm infants born between 2008 and 2021 in the Netherlands: a cohort study

ObjectivesThis study investigated changes in the length of stay (LoS) at a level III/IV neonatal intensive care unit (NICU) and level II neonatology departments until discharge home for very preterm...

Falls in oxygen saturations accompany electrographic seizures in term neonates: an observational study

BackgroundEffective seizure detection is important however, clinical signs of seizure activity may be subtle in neonates. This study aimed to systematically investigate SpO2 and respiratory pattern changes associated with EEG seizures in term-born neonates.MethodAn observational study in term neonates at risk of seizures admitted to a single tertiary level neonatal intensive care unit. Synchronised high-resolution physiological data (ECG, pulse oximetry, respiration) and EEG/amplitude-integrated EEG (aEEG) monitoring were recorded. Sections of traces with evidence of clear EEG seizure activity were compared with physiological data recorded at the same time.Results22/44 (50%) neonates who had aEEG monitoring were noted to have electrographic seizures. Physiologic download measurements were available for 11 of these neonates. In nine of these, an acute drop in oxygen saturation (SpO2) of at least 5% was noted in at least one seizure. Accompanying apnoeas were noted in three neonates.ConclusionAcute decreases in SpO2 were seen in term neonates associated with seizures and these were not always accompanied by an apnoeic episode. Physiologic download in association with EEG monitoring may assist in improving seizure detection. Unexplained drops in SpO2 could indicate further investigation for possible seizures in at-risk neonates.ImpactA decrease in blood oxygen saturation (SpO2) associated with EEG seizures can occur in term infants with HIE or perinatal stroke.Drops in SpO2 associated with EEG seizures in term infants with HIE or stroke may occur in the absence of apnoeas.Unexplained acute falls in SpO2 in sick neonates may suggest possible seizures.Drops in SpO2 associated with seizures in term infants can occur over less than 3 minutes.Physiological monitoring alongside EEG monitoring could help to improve seizure detection.

TOPS score (T-temperature, O-Oxygen saturation, P- Perfusion, S- Sugar) on admission in transported neonates to tertiary care hospital

In India, 70% of deliveries take place in rural areas and the transport of the preterm babies to a tertiary care centre are referred only after the birth Babies must be transported to a higher level neonatal intensive care unit (NICU) to overcome the negative effects of critical illness such as respiratory distress and asphyxia in newborns. Most of the neonates are transported without any pre-transport stabilization or care during transport, which can have serious clinical implications on the ultimate outcome of babies. To assess the clinical condition and presence of complications among neonates transported to NICU. To predict outcome of transported neonates in terms of morbidity and mortality based on TOPS score. A cross-sectional observational study was conducted among 500 newborns admitted in NICU, at New Civil Hospital, Surat. Out of total, 258(51.3%) and 245(48.7%) patients were respectively males and females in the study. Out of the 503referred neonates 258 (51.3%) were referred for respiratory distress and ventillatory support, 138(27.4%) were referred for LBW / prematurity. The hypothermia was present post transport approximately among 64% neonates. Hypoglycaemia was found in only 18% of transported neonates. 33% of the studies neonates were hypoxic on reaching the referral centre and the remaining maintained spo2 above 90%.The high sensitivity (81%) and high negative predictive value (87.4%) with a specificity of 61.5% and positive predictive value of 59.7% suggest that TOPS score a very strong screening test to predict the outcome of babies admitted.

Investigating environmental transmission to resolve a Bacillus cereus group outbreak in a neonatal intensive care unit using core genome multilocus sequence typing

BackgroundWe analyzed an outbreak of Bacillus cereus group (Bcg) at a single-center neonatal intensive care unit level IV by conducting comprehensive sampling of both patients and the environment.MethodsBetween 06/2020 and 10/2021, all Bcg isolates identified by both regular colonization screening and additional sampling of the environment were subjected to whole-genome sequencing, followed by in vitro extraction of MLST ST, resistance genes and virulence factors. Using publicly available genome sequences, we defined an ad hoc core genome multilocus sequence typing (cgMLST) scheme comprising 2759 target genes for Bcg typing, which we applied to the detected isolates. We have compared the results with a stable cgMLST that was published in the meantime and completed the investigation with a SNP analysis.ResultsWe analyzed 28 Bcg isolates from patient and environmental samples using MLST and cgMLST. This revealed multiple sequence types, with ST127 being the most common (n = 13). Both cgMLST schemes grouped ten of the 13 ST127 isolates into a cluster, including two invasive isolates from two different patients and several environmental samples. SNP analysis postulated a screen from a ventilation machine as a possible reservoir.ConclusionIn sensitive settings such as neonatal intensive care units, considering the environment in outbreak analyses is crucial, especially when investigating potential transmission routes through shared devices. When dealing with widespread bacteria such as Bcg, high-resolution typing techniques are necessary. In this study, we successfully resolved an outbreak of Bcg infections using a custom cgMLST scheme combined with a SNP analysis.

The outcomes of specific surgically correctable congenital gastro-intestinal malformations at a tertiary level neonatal intensive care unit in South Africa

Background: The outcome of neonates with congenital surgically correctable gastro-intestinal (GIT) malformations is poorly described in low middle income countries. Methods: A 5-year retrospective descriptive analysis of neonates admitted to a tertiary level neonatal intensive care unit (NICU), with congenital, surgically correctable GIT malformations, was performed. The primary outcome was the 30-day postoperative mortality as well as survival to 1 year. Secondary outcomes included patient demographics, clinical presentation as well as the burden of disease in our study population. Results: Eighty-four neonates met study criteria. The mean gestational age was 35 weeks (SD 3.19) and birthweight 2518g (SD 789.3). The most common congenital malformations were intestinal atresia (39%) followed by omphaloceles (21%). Associated systemic malformations were common (39%). The majority of neonates (88%) underwent surgery at a median age of 2 days (IQR 1.5-5). Ventilation was required in 19% of neonates preoperatively and 65% postoperatively. Full feeds were achieved at a median age of 13 days (IQR 9-18) after surgery. The 30 day-postoperative survival rate was 97% with a survival to discharge or transfer of 86%. Data for one year survival was available for 80% of neonates with a one-year survival rate of 75%. Conclusion: The 30-day postoperative survival was high in neonates with congenital, surgically correctable GIT malformations. Outcomes and burden on the healthcare system was dependent on the type of lesion. With early diagnosis and referral to a tertiary centre, good outcomes can be achieved. Neonates with congenital GIT malformations should have long term follow up to monitor growth and neurodevelopment as well as to address the high mortality post discharge.

Reduction of Environmental Noise Impact on Preterm Babies in NICU by Using Ear Plugs

Objective − To determine if using ear plugs reduce the impact of noise on preterm babies admitted to neonatal intensive care units in terms of changes in their vital parameters and their discomfort level, assessed using the Neonatal Infant Pain Scale (NIPS) score.Materials and Methods − This is an interventional study conducted in a tertiary level neonatal intensive care unit (NICU) (Bangalore, India) over a period of 3 months, ranging from June 2022 to September 2022. This study included 20 preterm babies with different gestational ages and birth weights who were admitted to the NICU during that period. The babies’ response to noise, in terms of changes in heart rate, respiratory rate, blood pressure, oxygen saturation and discomfort level, were assessed with ear plugs and without ear plugs on alternate days and the results were recorded. Descriptive statistics were used for statistical analysis. Results − On days 1 and 3, mean heart rate and systolic blood pressure were lower in babies wearing ear plugs (141.55±2.42 SD and 60.1±11.58, respectively) than in the same babies without ear plugs (157.55±2.52 SD and 61.85±1.6 SD, respectively) on days 2 and 4. The mean oxygen saturation was higher in babies wearing ear plugs (96.7%±0.80 SD) than in the same babies without the intervention (93.75%±1.29 SD). The mean NIPS score was lower with the intervention (2.05±0.22) than without ear plugs (5.05±0.22 SD).Conclusion – Ear plugs were an effective alternative in situations where noise in the NICU cannot be consistently maintained at a lower level than the standard recommendation by the AAP of 45 decibels.

Outbreak of nosocomial sepsis in NICU by multidrug-resistant Klebsiella pneumoniae: Diagnostic challenges

Purpose: Nosocomial infections are a serious problem in neonatal intensive care units (NICU) – they are one of the main causes of morbidity and mortality among preterm newborns. Material/methods: We present a prospective clinical-epidemiological study of an outbreak of 7 cases of culture-proven multidrug-resistant (MDR) Klebsiella pneumoniae late onset sepsis in a period of 2 months in a tertiary level NICU in Pleven, Bulgaria. The risk factors, early clinical presentation, laboratory changes, course of infection, treatment, and outcome were evaluated. Results: Three of our patients were term infants, the other four patients were preterm aged from 25 to 36 gestational weeks. The most possible routs of transmission of the infection were: venous lines, mechanical ventilation, tube feeding. Аll of the mentioned were present in one extremely immature patient. Early clinical signs included skin color changes, abnormal muscle tone, respiratory failure. Laboratory tests taken at the time of onset revealed leucopenia and/or thrombocytopenia in a half of the cases and usually C-reactive protein remained normal, but in all cases the I/T ratio increased significantly. The clinical course varied from fulminant deterioration to easily controlled condition. Treatment with Meropenem was started at the time of clinical suspicion of infection, according to the antibiogram of the first cases. No fatal outcome was observed. Conclusion: Main causes for the outbreak of hospital acquired infection were overcrowding of the NICU, admission of patients from lower-level hospitals, insufficient working staff, especially midwifes. The early diagnosis and proper antimicrobial treatment were crucial for the favorable outcome.

70 Purpose-built Catheters for Minimally Invasive Surfactant Therapy – Experience from a Canadian Tertiary Level Neonatal Intensive Care Unit

Abstract Background Surfactant delivery via a thin endotracheal catheter during spontaneous breathing (a technique called minimally invasive surfactant therapy [MIST]), is an increasingly popular alternative to intubation and surfactant administration. Procedural details among different centres vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess catheters and vascular catheters for this purpose. Recently, purpose-built catheters for MIST received regulatory approval in Canada and became available for use. Procedural differences and user experiences between such catheters have not been described. Objectives The aim of this study was to describe procedural success, procedural adverse effects and user experience pertaining to two different types of purpose-build catheters (BLEScath™ and Surfcath™) for surfactant administration. Design/Methods This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit (NICU) in Southwestern Ontario. Neonates who received MIST using purpose-built catheters between January 1, 2021 and March 31, 2022 were included. Two types of purpose-built catheters were used in this time period: Surfcath™ and BLEScath™. Relevant baseline characteristics and data on procedural details (premedication, type of catheter) were collected. The procedural success, number of attempts and adverse effects among neonates who received MIST via Surfcath™ and those who received surfactant via BLEScath™ were compared, using chi-square tests or Fisher’s tests, as appropriate. User experience was described using an ease-of-use scale. Descriptive reports of user experience were collected and explored for themes/patterns. P-values <0.05 were considered statistically significant. Results 37 neonates met eligibility criteria; 22 received MIST via Surfcath™, whereas 15 received MIST via BLEScath™. Success rates were 91% in SurfCath™ and 93% in BLES-Cath (P> 0.994). Failed attempts were lower in Surfcath™ (23%) compared with BLEScath™ (33%), but the difference was not statistically significant (p=0.708). Upon analyzing ease-of-use by operators, we found that 90% of operators found Surfcath™ very easy or relatively easy to use, compared with 43% of users reflecting the same degree of use with BLEScath™ (P=.021). Users described difficulty in ‘maneuvering’ the BLEScath™ and reported it to be ‘pliable/ flimsy’. There was no difference in adverse events between groups. Conclusion This is the first study in Canada to report the experience of MIST with purpose-built catheters. Overall success rate was equally high for both catheters. Users subjectively reported higher ease of use with SurfCath™. Commercially available purpose-built catheters should facilitate universal adaptation of the MIST method. Our reports regarding operator experience may help with optimizing future product design to improve ease-of-use.

Impact of Targeted Neonatal Echocardiography on Patent Ductus Arteriosus Management in a Canadian Tertiary Care Neonatal Unit: A Retrospective Cohort Study.

Comprehensive assessment of hemodynamic significance of a patent ductus arteriosus (PDA) is a common indication to perform targeted neonatal echocardiography (TNE). Impact of implementation of such an assessment on PDA management decisions remains to be reported. The objective of this study is to compare PDA-related hemodynamic information and PDA treatment decisions before and after introduction of TNE service. This was a retrospective cohort study at a tertiary level neonatal intensive care unit in Southwestern Ontario. We investigated two time periods: Epoch-1 (non-TNE 2013-2016) versus Epoch-2 (TNE 2018-2021). We included neonates < 32 weeks with PDA. Data on baseline clinical characteristics, PDA-related echocardiographic parameters, PDA treatment details, and relevant long-term outcomes were collected. Primary outcome was defined as PDA treatment rates and need for multiple courses. Secondary outcomes included availability of PDA hemodynamic data and neonatal mortality/morbidity (PDA-related) RESULTS: A total of 275 neonates were included. A total of 162 were assessed by conventional echocardiography in Epoch-1, whereas 113 were assessed by TNE in Epoch-2. Baseline clinical characteristics were similar. Epoch-2 had more echocardiographic assessments per patient of 2.7 (±1.8) versus 1.9 (± 1.3), p < 0.001 in Epoch1. The mean postnatal age at first echocardiographic assessment was higher in Epoch-2 (12.7 days [ ± 14.6]) than in Epoch-1 (7.9 days [ ± 10.4]), p < 0.001. Comprehensive hemodynamic assessment of PDA-related echocardiographic parameters such as PDA size, shunt pattern, effect on systemic circulation, and pulmonary circulation were higher in Epoch-2. Overall, PDA treatment rates were comparable in the two time periods. The use of multiple courses of treatment was higher in Epoch-1 than in Epoch-2 (47.8 vs. 31.7%, p = 0.047). In Epoch-1, neonates received PDA treatment earlier than in Epoch-2. With the implementation of the TNE service, increased echocardiographic evaluations per patient were completed with availability of more comprehensive hemodynamic information about PDA. PDA treatment rates were similar in the two epochs, but need for multiple courses were less in TNE era. · TNE allows comprehensive hemodynamic assessment of PDA.. · Implementation of dedicated TNE service led to increased use of echocardiography to assess PDA.. · Standardized hemodynamic assessment of PDA may allow improved individualization of treatment need..

Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns.

Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development. Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled. We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001). The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.

Evaluation of the efficacy and associated complications of regional citrate anticoagulation in neonates: experience from a fourth level neonatal intensive care unit.

RCA was an efficient and safe anticoagulation for neonates requiring CKRT. Metabolic complications may occur, but they could be managed with adequate supplementation. • Continuous kidney replacement therapy (CKRT) has become popular in recent years due to its successful treatment of fluid overload, electrolyte imbalance, metabolic acidosis, multi-organ failure, and hyperleucinemia/hyperammonemia associated with inborn errors of metabolism. • The need for anticoagulation is the major difficulty in neonatal CKRT. In adult and pediatric patients, regional citrate anticoagulation has been shown to be effective. • RCA is an effective and safe anticoagulation method for neonates who require CKRT. • Electrolyte imbalances and metabolic acidosis could be managed with adequate supplementation and appropriate treatment parameters such as citrate dose, blood flow rate, and dialysate flow rate.

Stress, Anxiety, and Postpartum Depression in Parents with Premature Infants in Neonatal Intensive Care Unit.

This study aimed to determine stress, anxiety, and postpartum depression in parents with premature infants in neonatal intensive care unit. This cross-sectional study was conducted between July 15 and November 31, 2021. The research involved 120 premature infants and their parents (120 mothers and 120 fathers). This research was carried out in Şanlıurfa Mehmet Akif İnan Training and Research Hospital, third level neonatal intensive care unit. Introductory Information Form, Parental Stress Scale: Neonatal Intensive Care Unit, Beck Anxiety Inventory, and Edinburgh Postpartum Depression Scale were used as data collection tools. Stress, anxiety, and depression were high in parents. Stress, anxiety, and postpartum depression mean scores of mothers were significantly higher than that of fathers. A positive correlation was found between stress, anxiety, and postpartum depression in parents. Simple regression analysis revealed that stress in mothers predicted depression by 5% and stress in fathers predicted anxiety by 30%. This study emphasizes that stress, anxiety, and depression are seen at high rates in parents with premature infants, and stress increases anxiety in fathers and depression in mothers.

Purpose Built Catheters for Minimally Invasive Surfactant Therapy: Experience from a Canadian Tertiary Level Neonatal Intensive Care Unit.

Minimally invasive surfactant therapy (MIST), a method of surfactant delivery via a thin catheter during spontaneous breathing, is an increasingly popular alternative to intubation and surfactant administration. Recently, purpose-built catheters for MIST received regulatory approval in Canada and became available for use. However, procedural success and user experience with such catheters have not been described. This retrospective cohort study included neonates who received MIST using purpose-built catheters between January 1, 2021, and March 31, 2022. Two types of purpose-built catheters were used in this period - SurfCath™ and BLEScath™. Procedural success, number of attempts, and adverse events in neonates receiving MIST via the two catheters were compared using chi-square or Fisher's tests. User experience was described using an ease-of-use scale. Thirty-seven neonates met eligibility criteria; 22 received MIST via SurfCath™, whereas 15 received MIST via BLEScath™. Success rates were 91% in SurfCath™ and 93% in BLEScath™ (P> 0.994). Failed attempts were lower in SurfCath™ (23%) in comparison to BLEScath™ (33%), but the difference was not statistically significant (P=0.708). Among operators, 90% found SurfCath™ very easy/relatively easy to use compared to 43% of users reflecting the same degree of use with BLEScath™ (P=.021). There was no difference in adverse events. This is the first study in Canada to report MIST with purpose-built catheters. Overall, the success rate was equally high with both catheters. Users subjectively reported higher ease of use with SurfCath™. Commercially available purpose-built catheters should facilitate universal adaptation of the MIST method.

Assessing hospital differences in low-risk cesarean delivery metrics in Florida

Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care. This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only. This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term, singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term, singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term, singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level. Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased. Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term, singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term, singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.

Trends in Resources for Neonatal Intensive Care at Delivery Hospitals for Infants Born Younger Than 30 Weeks’ Gestation, 2009-2020

In an ideal regionalized system, all infants born very preterm would be delivered at a large tertiary hospital capable of providing all necessary care. To examine whether the distribution of extremely preterm births changed between 2009 and 2020 based on neonatal intensive care resources at the delivery hospital. This retrospective cohort study was conducted at 822 Vermont Oxford Network (VON) centers in the US between 2009 and 2020. Participants included infants born at 22 to 29 weeks' gestation, delivered at or transferred to centers participating in the VON. Data were analyzed from February to December 2022. Hospital of birth at 22 to 29 weeks' gestation. Birthplace neonatal intensive care unit (NICU) level was classified as A, restriction on assisted ventilation or no surgery; B, major surgery; or C, cardiac surgery requiring bypass. Level B centers were further divided into low-volume (<50 inborn infants at 22 to 29 weeks' gestation per year) and high-volume (≥50 inborn infants at 22 to 29 weeks' gestation per year) centers. High-volume level B and level C centers were combined, resulting in 3 distinct NICU categories: level A, low-volume B, and high-volume B and C NICUs. The main outcome was the change in the percentage of births at hospitals with level A, low-volume B, and high-volume B or C NICUs overall and by US Census region. A total of 357 181 infants (mean [SD] gestational age, 26.4 [2.1] weeks; 188 761 [52.9%] male) were included in the analysis. Across regions, the Pacific (20 239 births [38.3%]) had the lowest while the South Atlantic (48 348 births [62.7%]) had the highest percentage of births at a hospital with a high-volume B- or C-level NICU. Births at hospitals with A-level NICUs increased by 5.6% (95% CI, 4.3% to 7.0%), and births at low-volume B-level NICUs increased by 3.6% (95% CI, 2.1% to 5.0%), while births at hospitals with high-volume B- or C-level NICUs decreased by 9.2% (95% CI, -10.3% to -8.1%). By 2020, less than half of the births for infants at 22 to 29 weeks' gestation occurred at hospitals with high-volume B- or C-level NICUs. Most US Census regions followed the nationwide trends; for example, births at hospitals with high-volume B- or C-level NICUs decreased by 10.9% [95% CI, -14.0% to -7.8%) in the East North Central region and by 21.1% (95% CI, -24.0% to -18.2%) in the West South Central region. This retrospective cohort study identified concerning deregionalization trends in birthplace hospital level of care for infants born at 22 to 29 weeks' gestation. These findings should serve to encourage policy makers to identify and enforce strategies to ensure that infants at the highest risk of adverse outcomes are born at the hospitals where they have the best chances to attain optimal outcomes.

Pattern of microbial profile and their susceptibility pattern in a tertiary level neonatal intensive care unit, Dubai, UAE: 11 years surveillance study

Introduction: Neonatal sepsis is a global burden on the health and wellbeing of the neonates. It mounts too many neonatal mortality and morbidity. However, rational use of antimicrobial therapy and aggressive supportive management has modified the outcome over the past few decades. A good knowledge of locally prevalent microbes and antibiotics sensitivity pattern help in formulating antibiotics regimen. Methodology: This study is a retrospective analysis of prevalent microorganisms isolated from various culture samples collected from neonates aged 0 - 90 days, suspected to have early or late onset neonatal sepsis. All the neonates were admitted to Neonatal intensive care unit (NICU) of Latifa Women and Children Hospital (LWCH) over an 11 year period (from January 2011 till December 2021). Descriptive analyses were used with results presented as proportions. Data were analyzed using Microsoft excel 2016 and online calculators. Results: A total of 4849 microbial culture positive isolates were identified from our NICU. These isolates included samples taken from, blood, cerebrospinal fluid, endotracheal aspirates, throat/nasopharynx, urine, rectal, stool, eyes and superficial cultures. Gram-negative bacteria were isolated in 56.3% (n= 2730). Gram positive bacteria accounted for 43.7% (n=2119) of isolates. Most common isolated bacterial species were Klebsiella pneumoniae (15.7%), Coagulase Negative Staphylococcus (CONS) (14.6%), Stenotrophomonas maltophilia (11.5%) and Pseudomonas aeruginosa (11.1%). Among the multidrug resistant organism (MDRO), Extended spectrum beta lactamase (ESBL) K. pneumoniae (n=208, 4.3%) and Methicillin resistant staphylococcus aureus (MRSA) (n=145, 3%) are the predominant strain. Over the study period, there is a significant reduction in both gram positive and gram negative bacterias (n=1055 in 2011 to 226 in 2021). Discussion/conclusion: The need of the hour is implementation of strict infection control measures and rationalized use of broad-spectrum antibiotics and continuous surveillance of emergence of MDROs. Regular tracking of the microbiological prevalence pattern kept us updated regarding prevailing organisms and emergence of MDROs. Our NICU antimicrobial policy modified in accordance with the surveillance data.

Influences of Initial Empiric Antibiotics with Ampicillin plus Cefotaxime on the Outcomes of Neonates with Respiratory Failure: A Propensity Score Matched Analysis.

Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47-118.8] days versus 78 [45.0-106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes.

Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants

A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown. To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants. This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database. NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs). The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type. Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score. In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.