Onset Sepsis Research Articles

Kinetics of the Lactate to Albumin Ratio in New Onset Sepsis: Prognostic Implications.

The lactate to albumin ratio (LAR) has been associated with the severity and outcome of critical illness and sepsis. However, there are no studies on the kinetics of the LAR during the early phase of sepsis. Therefore, we aimed to investigate the LAR and its kinetics in critically ill patients with new onset sepsis regarding the severity and outcome of sepsis. We prospectively enrolled 102 patients with sepsis or septic shock within 48 h from diagnosis. LARs were recorded at inclusion in the study and one week later. Patients were followed for 28 days. LAR was significantly lower one week after enrollment compared to baseline in all patients (p < 0.001). LARs were significantly higher in patients with septic shock and in nonsurvivors compared to patients with sepsis and survivors, respectively, both at inclusion (p < 0.001, p < 0.001) and at one week later (p < 0.001, p < 0.001). LARs at baseline were positively associated with the severity of sepsis (APACHE II: r = 0.29, p = 0.003; SOFA: r = 0.33, p < 0.001) and inflammatory biomarkers, such as C-reactive protein (r = 0.29, p < 0.1), procalcitonin (r = 0.47, p < 0.001), interleukin 6 (r = 0.28, p = 0.005) interleukin 10 (r = 0.3, p = 0.002) and suPAR (r = 0.28, p = 0.004). In addition, a higher LAR, but not its kinetics, was an independent predictor of 28-day mortality (at inclusion: HR 2.27, 95% C.I. 1.01-5.09, p = 0.04; one week later: HR: 4.29, 95% C.I. 1.71-10.78, p = 0.002). In conclusion, the LAR may be a valuable prognostic indicator in critically ill patients with sepsis at admission and one week later.

25-hydroxyvitamin D and parathyroid hormone in new onset sepsis: A prospective study in critically ill patients

Hypovitaminosis D is highly prevalent in critically ill patients, and it has been suggested to be a risk factor for infections, sepsis and higher mortality. We sought to investigate whether serum 25-hydroxyvitamin D (25(OH)D) and parathyroid hormone (PTH) in critically ill patients with new onset sepsis are associated with severity and outcome. We prospectively included 50 consecutive critically ill adult cases with new onset sepsis and 50 healthy controls matched for age and sex. PTH and 25(OH)D were determined in serum via electrochemiluminescence immunoassays at inclusion in the study in all cases and controls, and one week after sepsis onset in cases. Patients had reduced 25(OH)D compared to controls at sepsis onset (7.9 ± 3 vs 24.6 ± 6.7 ng/mL, p < 0.001), whilst PTH was similar (median (range): 34.5 (5.7–218.5) vs 44.2 (14.2–98.1) pg/mL, p = 0.35). In patients, 25(OH)D upon enrollment and one week after did not differ significantly (7.9 ± 3 vs 7 ± 4.3 ng/mL, p = 0.19). All patients presented with hypovitaminosis D (25(OH)D < 20 ng/mL), while 40 patients (80 %) had vitamin D deficiency (25(OH)D < 12 ng/mL) at sepsis onset, including all ten (20 %) nonsurvivors, who died within 28 days from sepsis onset. Patients with sepsis (N = 28) and septic shock (N = 22) as well as survivors (N = 40) and nonsurvivors (N = 10) had similar 25(OH)D at enrollment (p > 0.05). 25(OH)D was positively correlated with ionized calcium (r = 0.46, p < 0.001) and negatively with PTH (p < 0.05), while inflammatory biomarkers or the severity scores exhibited no correlation with 25(OH)D. Patients with septic shock and nonsurvivors had lower PTH than patients with sepsis and survivors respectively (42.2 ± 42.9 vs 73.4 ± 61.9 pg/mL, p = 0.04, and 18.3 ± 10.7 vs 69.9 ± 58.8 pg/mL, p = 0.001, respectively). C-reactive protein was negatively associated with PTH (r = −0.44, p = 0.001). In conclusion, vitamin D deficiency was present in 80 % of critically ill patients at sepsis onset, while nonsurvivors exhibited lower PTH than survivors. Additional, larger and multicenter studies are warranted to elucidate the contribution of vitamin D and PTH to the pathogenesis of sepsis and its outcomes.

Effectiveness of Probiotics and Phototherapy Compared to Phototherapy Alone in Treating Hyperbilirubinemia in Neonates ≥35 Weeks Gestation: A Comparative Observational Study

Introduction Neonatal jaundice is a common condition in neonatal practice. Phototherapy is accepted first line of therapy in its treatment. Probiotics can be an addition as it decreases enterohepatic circulation and improves gut function. Materials and Methods The observational study was conducted in 40 neonates. Participants were divided into 2 groups, phototherapy alone (PA) and probiotics plus phototherapy (PP). The mean difference in total serum bilirubin (mg/dL) levels, total duration of phototherapy, incidence of rebound hyperbilirubinemia, frequency of stooling after initiation of therapy, feed intolerance, and occurrence of new onset sepsis was compared. Results The mean difference in serum bilirubin level was not statistically significant after 12 hours ( p = .321), 24 hours ( p = .544) and 48 hours ( p = .863) after initiation of phototherapy. An increase in frequency of stool in the first 24 hours was observed in PP group ( p = .003). The total duration of phototherapy was less in PP group although not statistically significant (25 hours vs 38 hours, p = .054). Rebound hyperbilirubinemia was significantly higher in PA ( p = .023). There were no cases of feed intolerance and sepsis. Conclusion The addition of probiotics did not alter the clinical course of jaundice. However, probiotics can reduce the rebound hyperbilirubinemia and is safe as it did not increase incidence of new onset sepsis or feed intolerance.

Prevalence of microbiologically confirmed neonatal sepsis at a maternity center in the City of Buenos Aires.

Introduction. Neonatal sepsis is often suspected in hospitalized newborn infants, but only in 25-30% of cases it is confirmed via a positive culture. Selecting the antibiotics based on local epidemiology favors their rational use and minimizes their side effects. Primary objective. To describe the prevalence of early- and late-onset sepsis with microorganism isolation and their clinical characteristics. Population and method. Retrospective, cross-sectional study conducted between 01-01-2013 and 12-31-2017 in a public maternity center of Argentina in all hospitalized newborn infants with a diagnosis of early- and late-onset sepsis with microorganism isolation, and those re-admitted in their first month of life. Results. A total of 3322 newborn infants were admitted; 1296 were assessed for suspected early- onset sepsis; 25 had a positive culture (1.9%; rate: 0.86‰). Of these, 52% were born before 33 weeks of gestation. Microorganisms: Escherichia coli 5, Listeria monocytogenes 4, Streptococcus agalactiae (SGB) 3, Streptococcus pneumoniae 3. Also, 68% of late-onset sepsis cases (rate: 8.73‰) occurred in infants born before 33 weeks of gestation. Hospital-acquired microorganisms: coagulase-negative Staphylococcus 115, Staphylococcus aureus 47, Escherichia coli 30, Candida spp. 16, Enterococcus faecalis 13, Klebsiella pneumoniae 11, and Streptococcus agalactiae 10. In re-admissions: E. coli 11, S. aureus 12, SGB 3, and Haemophilus influenzae 3. Conclusions. During the study period, the frequency of early-onset sepsis was similar to international reports, with a predominance of E. coli and L. monocytogenes. The rate of late-onset sepsis showed a downward trend in the analyzed years, with a predominance of Gram-positive cocci.

Bacteriological Profile and Antibiotic Susceptibility Pattern of Isolates in Neonatal Sepsis

Sepsis in newborns is a serious medical condition having a high mortality. Pakistan and other developing countries have a high burden of neonatal sepsis. Objectives: To determine the bacterial spectrum and antibiotic activity pattern in neonatal sepsis. Methods: This retrospective cross-sectional research was performed at the Pediatrics Unit of Ziauddin University Hospital Karachi from 1st June 2022 till 1st December 2022. A total of 120 medical records of neonates admitted with the clinical suspicion of sepsis were reviewed. Non-probability convenience sampling technique was used. Data regarding clinical characteristics of neonates, type of bacteria isolated and antibiotic susceptibility results were recorded. SPSS version 20 was used for statistical analysis. The results were written as frequencies / percentages. Results: Neonatal sepsis was suspected in 120 newborns but blood culture-proven infection was present in 32 (13.3%) neonates with 23(71.8%) having early -onset sepsis. The mean age on admission was 7.61±3.61 days. Acinetobacter was the commonest bacteria implicated in sepsis followed by Klebsiella ,Burkholderia and Serratia. The mortality rate in study population was 8.3%. Mortality was highest in Klebsiella sepsis. None of the bacterial species were sensitive to ampicillin while Acinetobacter and Burkholderia species responded to colistin, polymyxin and meropenem but showed resistance to imipenem. Conclusion: Early-onset neonatal sepsis has a high prevalence especially with gram -negative bacteria. Antimicrobial resistance to first line empiric therapy is common

Platelet parameters and the association with morbidity and mortality in Preterm Infants.

There is growing recognition of the role of platelets in inflammation and immune responses, and platelets have been associated with various cardiovascular diseases. It is also known that neonatal morbidities are related to overall platelet activity, and platelet parameters may have the potential to predict morbidities and mortality in preterm infants. This study aimed to assess the initial platelet parameters and the association with major morbidities and mortality in preterm neonates. We retrospectively reviewed data from very preterm neonates with a gestational age (GA) <32 weeks who were admitted between June 2020 and May 2021 for platelet parameters (counts, mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (platelet counts x MPV/10000(%)) at birth. Major morbidities included early- onset sepsis (EOS) ≤3 days after birth, severe intraventricular hemorrhage (IVH) grade ≥3, and early or overall mortality. A total of 197 very preterm neonates were studied. Their mean (±SD) GA was 28.0 ± 2.4 weeks, birth weight was 990 ± 293 g, platelet counts were 245 ± 81 x1000/μL, MPV was 10.0 ± 0.7 fl, PDW was 11.0 ± 1.6 fl, and plateletcrit was 0.24 ± 0.08%. MPV had a weak negative correlation with both GA (r = -0.234, p = 0.001) and BW (r = -0.343, p <0.001). A lower plateletcrit was associated with EOS (0.14 (0.04-0.22) % vs. 0.23 (0.19-0.30) %, p = 0.027), severe IVH ≤7 days after birth (0.18 (0.14-0.27) % vs. 0.23 (0.20-0.30) %, p = 0.022), and early and overall mortality (0.15 (0.20-0.30) % vs. 0.23 (0.20-0.30) %, p = 0.049; 0.20 ± 0.09 % vs. 0.25 ± 0.07 %, p = 0.008). A lower plateletcrit within 24 hours of birth was associated with EOS, severe IVH ≤7 days after birth, and first-week and overall mortality in very preterm neonates.

BIOCHEMICAL PROFILE, BACTERIAL PROFILE, AND ANTIBIOTIC SUSCEPTIBILITY PATTERN OF THE ISOLATES OF NEONATAL SEPTICEMIA IN TERTIARY CARE HOSPITAL, VISAKHAPATNAM

Objectives: The objective of the study was to determine sensitivity, specificity, and predictive values of C-reactive protein (CRP), leukocyte count, platelet count, and blood culture as indicators of neonatal sepsis. Methods: This prospective study was conducted in the Department of Paediatrics, GITAM Institute of Medical sciences and Research, Visakhapatnam during January 2019 to December 2019. The institutional ethics committee had approved the study. Eighty clinically suspected cases of neonatal sepsis constituted material of study. All neonates who were clinically suspected sepsis, categorized into 0–72 h (early onset) or late onset (&gt;3 days) sepsis based on day of presentation. Detailed history and clinical findings were recorded in the pro forma and screened with CRP and various hematological tests with predetermined cutoff values and at the same time blood culture was sent. Concerning a clinical scenario CSF, urine analysis, chest X-ray, and infective focus swabs were all taken. The length of treatment and time spent in the hospital were recorded. The death rate was calculated, and numerous risk variables were evaluated. Results: Intrapartum risk factors such as a prolonged rupture of membrane &gt;24 h, a long labor, several filthy vaginal examinations (&gt;3) before birth, and foul-smelling liquid were all linked to culture-proven newborn sepsis. Any of the two risk factors listed above was a good predictor of sepsis with a positive culture. Neonatal sepsis impacted a higher percentage of low birth weight and preterm babies. The sensitivity and negative predictive value of the I/T ratio and CRP were both high. The most prevalent isolates were Klebsiella species, followed by Staphylococcus aureus and Escherichia coli. While S. aureus was 80% sensitive to Cefotaxime and Amikacin, Klebsiella species and E. coli were only 20% sensitive. All were sensitive to Ofloxacin in range of 75-100%. Septicemia with multiorgan dysfunction was the most common mode of death with 100% risk of mortality. Conclusion: Intraparum risk factors are significantly with culture proven sepsis. All sepsis screening parameters used were statistically significantly associated with culture proven sepsis. I/T ratio and CRP were more sensitivity and had high negative predictive value. CRP can be used as an early and predictable screening test for diagnosing neonatal sepsis.

Etiology and antimicrobial susceptibility of neonatal sepsis in the Neonatal Intensive Care Unit in Can Tho Children’s Hospital

This study aimed to determine the causative organisms in neonatal sepsis and their antimicrobial resistance patterns in the Neonatal Intensive Care Unit (NICU) of Can Tho Children’s Hospital in Vietnam. A retrospective descriptive study of neonatal sepsis was conducted from January 2018 to December 2019. A total of 139 neonates with positive blood culture was analyzed. Gram - positive bacteria (n = 84, 60.4%) were more common than Gram - negative bacteria (n = 49, 35.3%) and fungi (n = 6, 4.3%). Coagulase - negative Staphylococci (CONS) (28.3%) and Klebsiella pneumoniae (13.2%) were the most common cause of Early - onset sepsis, while CONS (39.5%) and Staphylococcus aureus (22.1%) were predominant isolates of Late - onset sepsis. Almost CONS and S. aureus were resistant to ampicillin and oxacillin, but susceptible to vancomycin (92 - 94%) and lizenolid (100%). K. pneumonia was resistant to cefotaxime (67%) and gentamicin (30%), but susceptible to imipenem (92%). Conclusion: CONS, S. aureus and K. pneumoniae were the most frequent pathogens in neonatal sepsis in our settings. Almost these strains were resistant to commonly used antibiotics. Change of first - line drugs should be based on the identification of isolated organisms and appropriate implementation of likely susceptible antibiotics would have a substantial impact on the outcomes.

Early initiation of broad-spectrum antibiotics in premature infants

Neonatal sepsis remains one of the main reasons for mortality among premature infants, and the early initiation of empirical broad-spectrum antibiotics could increase the risk of complications, including late-onset sepsis. This study aimed to investigate the complications related to the use of empirical broad-spectrum antibiotics in the first week of life. A retrospective study of 365 neonates with gestational age ≤32 weeks and birth weight <1500 g who survived and had no confirmed sepsis in the first week of life from July 2015 to June 2018 was performed in a large tertiary Neonatal Intensive Care Unit. The primary outcome of this study was the incidence of a composite outcome consisting of late-onset sepsis, necrotizing enterocolitis, and mortality. The secondary outcomes were the incidences of late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and infant mortality. Of the 365 premature infants, 75 (20.5%) received broad-spectrum antibiotics. Multivariate regression analysis revealed that administration of broad-spectrum antibiotics in infants was independently associated with adverse outcomes. The composite outcome (late-onset sepsis, necrotizing enterocolitis, and death) had an odds ratio of 3.03 with 95% confidence interval of 1.41-6.49. Administration of empirical broad-spectrum antibiotics in the first week of life is associated with severe adverse outcomes. Thus, the restricted use of broad-spectrum antibiotics in the first week of life is recommended.

Early-onset sepsis risk calculator reduces empiric antibiotic use

Kuzniewicz MW, Puopolo KM, Fischer A, Walsh EM, Li S, Newman TB, et al. A Quantitative, Risk-Based Approach to the Management of Neonatal Early-Onset Sepsis. JAMA Pediatr 2017;171:365-71. Question Among newborns, what is the clinical benefit of an early-onset sepsis (EOS) risk calculator, compared with national guidelines, in reducing antibiotic use? Design Cohort. Setting Kaiser Permanente Northern California (KPNC). Participants Neonates, 35 weeks of gestation or older. Intervention EOS calculator or national guidelines. Outcomes Empiric antibiotic use. Main Results Fewer babies in the EOS calculator group experienced blood culture use: adjusted number needed to treat (aNNT) 13 (95% CI, 8 to 42), and less empirical antibiotic administration in the first 24 hours: aNNT, 56 (95% CI, 44 to 77) with no difference between 24 and 72 hours after birth and no clinical outcome differences. Conclusions An EOS calculator reduced neonatal blood culture and empiric antibiotic use. Commentary A liberal threshold for initiating antibiotic therapy in neonates, based on early-onset sepsis (EOS) risk factors with poor predictive value, has led to overuse of antibiotics in non-infected neonates. This contrasts starkly with the low prevalence of EOS. Antibiotic overuse early in life may have severe short-term and long-term adverse consequences.1Esaiassen E. Fjalstad J.W. Juvet L.K. van den Anker J. Klingenberg C. Antibiotic exposure in neonates and early adverse outcomes — a systematic review and meta-analysis.J Antimicrob Chemother. 2017; 72: 1858-1870Crossref PubMed Scopus (83) Google Scholar, 2Bailey L.C. Forrest C.B. Zhang P. Richards T.M. Livshits A. DeRusso P.A. Association of antibiotics in infancy with early childhood obesity.JAMA Pediatr. 2014; 168: 1063-1069Crossref PubMed Scopus (329) Google Scholar This large cohort study from KPNC investigated clinical management of term and near-term infants with suspected or proven EOS over a 6-year period. The remarkable 50% relative reduction in antibiotic use after introduction of an EOS-calculator was not followed by a delay in therapy for infected infants or an increase in readmissions. It is evident that not only the EOS-calculator but also a bundle of co-interventions including improved patient monitoring was implemented, most likely at the same time. Moreover, the KPNC-staff must have undergone rigorous training in order to use the EOS-calculator and follow the bundle of interventions appropriately. The authors are to be congratulated for this very successful approach. The use of an EOS calculator has the potential to reduce antibiotic overuse, especially in areas where maternal risk factors, earlier, may have been over-emphasized. However, similar results may be achieved with different approaches. We recently presented data from a population-based study of 168,000 term infants in Norway over a 3-year period. In our setting, with a tradition of not recommending therapy based on risk factors alone, the proportion of term infants receiving antibiotic therapy in the first week of life was 2.3% and mortality was low.3Fjalstad J.W. Stensvold H.J. Bergseng H. Simonsen G.S. Salvesen B. Rønnestad A. et al.Early onset sepsis and antibiotic exposure in term infants: a nationwide population-based study in Norway.Pediatr Infect Dis J. 2016; 35: 1-6Crossref PubMed Scopus (1) Google Scholar

Diagnostic and prognostic value of presepsin vs. established biomarkers in critically ill patients with sepsis or systemic inflammatory response syndrome.

Inflammatory biomarkers may aid to distinguish between systemic inflammatory response syndrome (SIRS) vs. sepsis. We tested the hypotheses that (1) presepsin, a novel biomarker, can distinguish between SIRS and sepsis, and (2) higher presepsin levels will be associated with increased severity of illness and (3) with 28-day mortality, outperforming traditional biomarkers. Procalcitonin (PCT), C-reactive protein (CRP), presepsin, and lactate were analyzed in 60 consecutive patients (sepsis and SIRS, n=30 per group) on day 1 (D1) to D3 (onset sepsis, or after cardiac surgery). The systemic organ failure assessment (SOFA) score was determined daily. There was no difference in mortality in sepsis vs. SIRS (12/30 vs. 8/30). Patients with sepsis had higher SOFA score vs. patients with SIRS (11±4 vs. 8±5; p=0.023), higher presepsin (AUC=0.674; p<0.021), PCT (AUC=0.791; p<0.001), CRP (AUC=0.903; p<0.0001), but not lactate (AUC=0.506; p=0.941). Unlike other biomarkers, presepsin did not correlate with SOFA on D1. All biomarkers were associated with mortality on D1: presepsin (AUC=0.734; p=0.0006; best cutoff=1843 pg/mL), PCT (AUC=0.844; p<0.0001), CRP (AUC=0.701; p=0.0048), and lactate (AUC=0.778; p<0.0001). Multiple regression analyses showed independent associations of CRP with diagnosis of sepsis, and CRP and lactate with mortality. Increased neutrophils (p=0.002) and decreased lymphocytes (p=0.007) and monocytes (p=0.046) were also associated with mortality. Presepsin did not outperform traditional sepsis biomarkers in diagnosing sepsis from SIRS and in prognostication of mortality in critically ill patients. Presepsin may have a limited adjunct value for both diagnosis and an early risk stratification, performing independently of clinical illness severity.

Long-Term Mortality in Patients Operated for Perforated Peptic Ulcer: Factors Limiting Longevity are Dominated by Older Age, Comorbidity Burden and Severe Postoperative Complications.

Perforated peptic ulcer (PPU) is a surgical emergency associated with high short-term mortality. However, studies on long-term outcomes are scarce. Our aim was to investigate long-term survival after surgery for PPU. A population-based, consecutive cohort of patients who underwent surgery for PPU between 2001 and 2014 was reviewed, and the long-term mortality was assessed. Survival was investigated by univariate analysis (log-rank test) and displayed using Kaplan-Meier survival curves. Multivariable analysis of risk factors for long-term mortality was assessed by Cox proportional hazards regression and reported as hazard ratio (HR) with 95% confidence intervals (CI). A total of 234 patients were available for the calculation of ninety-day, one-year and two-year mortality, and the results showed rates of 19.2% (45/234), 22.6% (53/234) and 24.8% (58/234), respectively. At the end of follow-up, a total of 109 of the 234 patients (46.6%) had died. Excluding 37 (15.2%) patients who died within 30days of surgery, 197 patients had long-term follow-up (median 57months, range 1-168) of which 36% (71/197) died during the follow-up period. In multivariable analyses, age >60years (HR 3.95, 95% CI 1.81-8.65), active cancer (HR 3.49, 95% CI 1.73-7.04), hypoalbuminemia (HR 1.65, 95% CI 0.99-2.73), pulmonary disease (HR 2.06, 95% CI 1.14-3.71), cardiovascular disease (HR 1.67, 95% CI 1.01-2.79) and severe postoperative complications (HR 1.76, 95% CI 1.07-2.89) during the initial stay for PPU were all independently associated with an increased risk of long-term mortality. Cause of long-term mortality was most frequently (18 of 71; 25%) attributed to new onset sepsis and/or multiorgan failure. The long-term mortality after surgery for PPU is high. One in every three patients died during follow-up. Older age, comorbidity and severe postoperative complications were risk factors for long-term mortality.

Multidrug-resistant organisms in neonatal sepsis in two tertiary neonatal ICUs, Egypt.

Neonatal sepsis remains a serious problem in any neonatal intensive care unit (NICU). Bacterial organisms have developed increased resistance to commonly used antibiotics. Because not enough data are available from Egypt, the aim of the present study was to determine the causative bacteria and the level of their resistance to commonly used antibiotics in tertiary NICUs in Cairo, Egypt. A 3.5-year retrospective study was carried out at NICUs of the Children's Hospital of Ain Shams University and that of El-Hussein Hospital, Al-Azhar University, Egypt. Records of neonates were reviewed. All neonates with culture-proven sepsis were included in the study. Almost one-third of the admitted neonates (33.4%) were diagnosed as having neonatal sepsis, 32.25% of them culture-proven. Early/late onset sepsis was found in 35.4 and 64.6%, respectively. Gram-negative/gram-positive bacteria was found in 68 to 25.6%. Fungal infection was detected in 9% of the isolates. Escherichia coli was the main pathogen isolated in both early-onset sepsis (41.2%) and late-onset sepsis (24.5%). Overall, 77% of the isolates were multidrug-resistant (60% of gram-positive bacteria and 83.4% of gram-negative bacteria). Nearly 80% (79%) of mortality was caused by multidrug-resistant organisms. Gram-positive and gram-negative bacteria showed high resistance against commonly used antibiotics such as ampicillin, amoxicillin, cefotaxime, ceftriaxone, and gentamicin. There is an alarming increase in antibiotic resistance to the commonly used antibiotics. Continuous surveillance for antibiotic susceptibility is needed to ensure proper empirical therapy. Improvement of infection control practices, avoidance of irrational use of antibiotics, and revision of the protocols are mandatory in the prevention of neonatal sepsis.

Implementation of a protocol proposed by the Brazilian National Health Surveillance Agency for antibiotic use in very low birth weight infants

Objective: To analyze the implementation of a protocol proposed by the Brazilian National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária – ANVISA) to improve sepsis diagnosis in very low birth weight newborns. Methods: This was a prospective study that evaluated the implementation of a protocol involving clinical and laboratory criteria (hematologic scoring system of Rodwell and C-reactive protein serial measurements), recommended by ANVISA, to improve the diagnosis of neonatal sepsis in very low birth weight newborns. The study included all patients who were born and remained in the neonatal intensive care unit until discharge or death, and excluded those with congenital diseases. The main outcomes measured in newborns before (2006-2007) and after implementation of the protocol (2008) were the rates of early and late sepsis, use of antibiotics, and mortality. Means were compared by Student's t-test and categorical variables were compared by the chi-squared test; the significance level for all tests was set at 95%. Results: The study included 136 newborns with very low birth weight. There was no difference between groups regarding general clinical characteristics in the studied periods. There was, however, a decrease in the number of diagnoses of probable early- onset sepsis (p < 0.001), use of antimicrobial regimens (p < 0.001), and overall mortality and infection-related mortality (p = 0.009 and p = 0.049, respectively). Conclusion: The implementation of the protocol allowed improvement of sepsis diagnosis by reducing the diagnosis of probable early-onset sepsis, thus promoting efficient antimicrobial use in this population.

The preterm gut microbiota: changes associated with necrotizing enterocolitis and infection

To describe gut colonization in preterm infants using standard culture and 16S gene rRNA profiling, exploring differences in healthy infants and those who developed NEC/late onset sepsis (LOS). Ninety-nine stools from 38 infants of median 27-week gestation were cultured; 44 stools from 27 infants had their microbial profiles determined by 16S. Ordination analyses explored effects of patient variables on gut communities. Standard microbiological culture identified a mean of two organisms (range 0-7), DGGE 12 (range 3-18) per patient. Enterococcus faecalis and coagulase negative staphylococci (CONS) were most common by culture (40% and 39% of specimens). Meconium was not sterile. No fungi were cultured. Bacterial community structures in infants with NEC and LOS differed from healthy infants. Infants who developed NEC carried more CONS (45% vs 30%) and less Enterococcus faecalis (31% vs 57%). 16S identified Enterobacter and Staphylococcus presence associated with NEC/LOS, respectively. Important differences were found in the gut microbiota of preterm infants who develop NEC/LOS. The relationship of these changes to current practices in neonatal intensive care requires further exploration.

Minimally invasive 'step-up approach' versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868

BackgroundThe initial treatment of acute necrotizing pancreatitis is conservative. Intervention is indicated in patients with (suspected) infected necrotizing pancreatitis. In the Netherlands, the standard intervention is necrosectomy by laparotomy followed by continuous postoperative lavage (CPL). In recent years several minimally invasive strategies have been introduced. So far, these strategies have never been compared in a randomised controlled trial. The PANTER study (PAncreatitis, Necrosectomy versus sTEp up appRoach) was conceived to yield the evidence needed for a considered policy decision.Methods/design88 patients with (suspected) infected necrotizing pancreatitis will be randomly allocated to either group A) minimally invasive 'step-up approach' starting with drainage followed, if necessary, by videoscopic assisted retroperitoneal debridement (VARD) or group B) maximal necrosectomy by laparotomy. Both procedures are followed by CPL. Patients will be recruited from 20 hospitals, including all Dutch university medical centres, over a 3-year period. The primary endpoint is the proportion of patients suffering from postoperative major morbidity and mortality. Secondary endpoints are complications, new onset sepsis, length of hospital and intensive care stay, quality of life and total (direct and indirect) costs. To demonstrate that the 'step-up approach' can reduce the major morbidity and mortality rate from 45 to 16%, with 80% power at 5% alpha, a total sample size of 88 patients was calculated.DiscussionThe PANTER-study is a randomised controlled trial that will provide evidence on the merits of a minimally invasive 'step-up approach' in patients with (suspected) infected necrotizing pancreatitis.

Acute Kidney Injury Due to Hypervitaminosis D in an Infant

We report here a case of bilateral pelviureteric junction stones in a 2 months old baby who presented with acute onset anuria and sepsis. The baby was diagnosed to have acute postrenal failure due to obstructive bilateral ureteric stones based on the findings of ultrasound scan. This was a rare case of drug-induced hypercalcemia resulting from inappropriate iatrogenic supplementation of calcium and Vitamin D. Baby later developed hydrocephalus as sequelae to meningitis. Magnetic resonance imaging of brain showed periventricular calcification probably a sequelae to hypercalcemia. Our case emphasizes the need for considering iatrogenic hypercalcemia as a cause of urolithiasis and other forms of calcification in infants.