Tertiary-level Neonatal Intensive Care Unit Research Articles

Thrombocytopenia-related outcome and pattern in preterm neonates hospitalized in neonatology unit: A single-center experience

Abstract: BACKGROUNDS: In preterm newborns, thrombocytopenia is one of the most often observed hematologic findings. Most cases of thrombocytopenia are mild to moderate, self-limiting, and have a short duration; nevertheless, in rare cases, it can result in serious complications including pulmonary hemorrhage that lead to death and morbidity. OBJECTIVES: The objective of this study was to identify the pattern, risk factors, and outcome of thrombocytopenia in preterm neonates hospitalized in a tertiary-level neonatal intensive care unit (NICU). PATIENTS AND METHODS: All sick preterm neonates who developed thrombocytopenia within the first 28 days of life admitted to the NICU were included. A platelet count was performed at presentation time and as needed after that. Thrombocytopenia-related morbidities (intraventricular hemorrhage, pulmonary hemorrhage, and sepsis), mortality, and risk factors were analyzed concerning severity (mild, moderate, and severe) and age of thrombocytopenia onset (early and late) in preterm neonates. RESULTS: A total of 100 preterm neonates were admitted to our NICU. Of these, 48% of neonates developed thrombocytopenia. In terms of severity, mild, moderate, and severe thrombocytopenia were present in 62.5%, 37.5%, and 16.7% of newborns, respectively. The prevalent risk factors for late-onset thrombocytopenia (LOT) were necrotizing enterocolitis (NEC) and late-onset sepsis; for early-onset thrombocytopenia, the risk factors were pregnancy-induced hypertension and early-onset sepsis. Neonates with sepsis, severe birth asphyxia, and NEC were significantly associated with severe thrombocytopenia (P < 0.001). Thrombocytopenia-related morbidities and mortality were significantly higher among moderate-to-severe thrombocytopenia cases (P < 0.001). CONCLUSIONS: Sepsis was the most common risk factor associated with severe and LOT. Compared to mild/moderate thrombocytopenia, severe thrombocytopenia required more platelet transfusions, was associated with major bleeding manifestations, and had a higher mortality rate. When caring for premature newborns, these issues need to be taken into account.

Comparing conventional and modified Seldinger techniques using a micro-insertion kit for PICC placement in neonates: a retrospective cohort study.

This study aims to assess the comparative effectiveness of a conventional splitting needle or a peelable cannula vs. the modified Seldinger technique (MST) by utilizing a dedicated micro-insertion kit across various clinically significant metrics, including insertion success, complications, and catheter-related infections. We conducted a retrospective observational cohort study using an anonymized data set spanning 3 years (2017-2019) in a large tertiary-level neonatal intensive care unit in Qatar. A total of 1,445 peripherally inserted central catheter (PICC) insertion procedures were included in the analysis, of which 1,285 (89%) were successful. The primary indication for insertion was mainly determined by the planned therapy duration, with the saphenous vein being the most frequently selected blood vessel. The patients exposed to MST were generally younger (7 ± 15 days vs. 11 ± 26 days), but exhibited similar mean weights and gestational ages. Although not statistically significant, the MST demonstrated slightly higher overall and first-attempt insertion success rates compared to conventional methods (91 vs. 88%). However, patients undergoing conventional insertion techniques experienced a greater incidence of catheter-related complications (p < 0.001). There were 39 cases of catheter-related bloodstream infections (CLABSI) in the conventional group (3.45/1,000 catheter days) and eight cases in the MST group (1.06/1,000 catheter days), indicating a statistically significant difference (p < 0.001). Throughout the study period, there was a noticeable shift toward the utilization of the MST kit for PICC insertions. The study underscores the viability of MST facilitated by an all-in-one micro kit for neonatal PICC insertion. Utilized by adept and trained inserters, this approach is associated with improved first-attempt success rates, decreased catheter-related complications, and fewer incidences of CLABSI. However, while these findings are promising, it is imperative to recognize potential confounding factors. Therefore, additional prospective multicenter studies are recommended to substantiate these results and ascertain the comprehensive benefits of employing the all-in-one kit.

Serial tissue Doppler imaging in the evaluation of bronchopulmonary dysplasia-associated pulmonary hypertension among extremely preterm infants: a prospective observational study.

To evaluate serial tissue Doppler cardiac imaging (TDI) in the evolution of bronchopulmonary dysplasia-associated pulmonary hypertension (BPD-PH) among extremely preterm infants. Prospective observational study. Single-center, tertiary-level neonatal intensive care unit. Infant born <28 weeks gestation. Utility of TDI in the early diagnosis and prediction of BPD-PH and optimal timing for screening of BPD-PH. A total of 79 infants were included. Of them, 17 (23%) had BPD-PH. The mean gestational age was 25.9 ± 1.1 weeks, and mean birth weight was 830 ± 174 g. The BPD-PH group had a high incidence of hemodynamically significant patent ductus arteriosus (83% vs. 56%, p < 0.018), longer oxygen days (96.16 ± 68.09 vs. 59.35 ± 52.1, p < 0.008), and prolonged hospital stay (133.8 ± 45.9 vs. 106.5 ± 37.9 days, p < 0.005). The left ventricular eccentricity index (0.99 ± 0.1 vs. 1.1 ± 0.7, p < 0.01) and the ratio of acceleration time to right ventricular ejection time showed a statistically significant trend from 33 weeks (0.24 ± 0.05 vs. 0.28 ± 0.05, p < 0.05). At 33 weeks, the BPD-PH group showed prolonged isovolumetric contraction time (27.84 ± 5.5 vs. 22.77 ± 4, p < 0.001), prolonged isovolumetric relaxation time (40.3 ± 7.1 vs. 34.9 ± 5.3, p < 0.003), and abnormal myocardial performance index (0.39 ± 0.05 vs. 0.32 ± 0.03, p < 0.001). These differences persisted at 36 weeks after conceptional gestational age. TDI parameters are sensitive in the early evolution of BPD-PH. Diagnostic accuracy can be increased by combining the TDI parameters with conventional echocardiographic parameters. BPD-PH can be recognizable as early as 33-34 weeks of gestation.

Association of Shift-Level Organizational Factors with Nosocomial Infection in the Neonatal Intensive Care Unit

ObjectiveTo evaluate the association between shift-level organizational data (unit occupancy, nursing overtime ratios (OTRs), and nursing provision ratios (NPRs)) with nosocomial infection (NI) among very preterm infants in the Neonatal Intensive Care Unit (NICU). Study DesignMulticentre, retrospective cohort study, including 1921 infants 230–326 weeks’ gestation admitted to three tertiary-level NICUs in Quebec between 2014-2018. Patient characteristics and outcomes (NI) were obtained from the Canadian Neonatal Network database and linked to administrative data. For each shift, unit occupancy (occupied/total beds), OTR (nursing overtime hours/total nursing hours), and NPR (number of actual/number of recommended nurses) were calculated. Mixed-effect logistic regression models were used to calculate adjusted odds ratios (aOR) for the association of organizational factors (mean over 3 days) with the risk of NI on the following day for each infant. ResultsRate of NI was 11.5% (220/1921). Overall, median occupancy was 88.7% [interquartile range, IQR, 81.0-94.6], OTR 4.4% [IQR 1.5-7.6], and NPR 101.1% [IQR 85.5-125.1]. A higher 3-day mean OTR was associated with higher odds of NI (aOR 1.08, 95% CI 1.02-1.15), a higher 3-day mean NPR was associated lower odds of NI (aOR 0.96, 95% CI 0.95-0.98), and occupancy was not associated with NI (aOR, 0.99, 95% CI 0.96-1.02). These findings were consistent across multiple sensitivity analyses. ConclusionNursing overtime and nursing provision are associated with the adjusted odds of NI among very preterm infants in the NICU. Further interventional research is needed to infer causality.

Application of Video Laryngoscopy for Minimally Invasive Surfactant Therapy: A Retrospective Comparative Cohort Study.

To compare procedural success, operator ease of use, and complication of MIST using VL vs. MIST using DL. This was a retrospective, observational cohort study conducted at a tertiary-level neonatal intensive care unit after obtaining ethical approval. We included neonates who received MIST between 1 October 2020 and 31 October 2022. Baseline demographic characteristics, along with procedural data, were collected. Primary outcome measures included the overall procedural success rate, the need for multiple attempts, and the total number of attempts. Secondary outcome measures included the occurrence of adverse events, the need for a second dose of surfactant, and the need for intubation within 7 days of the procedure. Means and SDs, independent t-tests, frequencies, and chi-square were used as appropriate. p-values < 0.05 were considered statistically significant. Of the 79 neonates included, 37 neonates received MIST via VL, while 42 received MIST via DL. The median gestational age was lower in the VL group at 29.0 weeks vs. 30.5 weeks (p = 0.011) in the DL group. The median birthweight in the VL group was 1260 g, IQR (1080, 1690), which was significantly lower than the DL group, which was 1575 g, IQR (1220, 2251), p = 0.028. Purpose-built catheter use was higher in the DL group. The overall procedural success was similar between groups. The need for multiple attempts was lower with VL in comparison to DL [4 (11%) vs. 13 (31%); p = 0.034)] at the univariate level but not significant at multivariate analysis (p = 0.131). Procedural complications, the need for a second dose of surfactant, the need for mechanical ventilation post-MIST, and operator ease of use were similar. User comments emphasized the value of VL in providing real-time visual information to confirm catheter placement and guide operators/trainees. Overall, in our cohort, despite VL being a more recently adapted technology used more in smaller, sicker, and more premature neonates, procedural success, complications, and operator ease of use for MIST using VL and DL were comparable. Our findings show the successful application of VL for MIST and suggest procedural advantages that might facilitate universal adoption.

Placement of peripherally inserted central catheters in neonates: A retrospective study.

Peripherally inserted central catheters (PICCs) are commonly used in neonatal intensive care units for extended intravenous nutrition and therapy. The selection of PICCs insertion sites can significantly influence insertion outcomes and neonatal safety. This study aimed to determine the most suitable insertion site in the lower extremities for neonatal PICCs. A retrospective case note review was conducted on PICCs inserted through lower extremity (LE) sites in a 40-bed tertiary-level neonatal intensive care unit at a university teaching hospital. The dates when data were accessed for research purposes were from June 2019 to June 2022. In total, 223 neonates were identified as having had PICCs, with 254 catheters inserted in the lower extremities. The STROBE checklist guided the reporting of this study. Neonates underwent PICC insertion via the LE vein, with an overall complication rate of 13.4% and a one-attempt success rate of puncture of 86.2%. The rates of complications, catheter occlusion, and catheter-related infection in the PICC group with insertion through the great saphenous vein were significantly lower than those in the femoral vein group (p < .05). The success rate was significantly higher than that in the femoral vein group (p < .05). Additionally, the incidence of total complications and catheter occlusion complications with PICC insertion via the right LE was significantly lower than that with insertion via the left LE (p < .05). Our study suggested that, when feasible, the saphenous vein in the right LE could be the most suitable insertion site for neonatal PICCs. These findings provide insights into the complications, indwelling time, and safety of neonatal PICCs in different LE sites, serving as a valuable reference for clinical practice. This study was retrospective in nature, and all staff involved obtained approved access to patient clinical data. Ethical approval was granted by the Ethics Committee of Xiangya Hospital, Central South University (registry number 2022010001).

Diagnostic utility of lung ultrasound in predicting the need for surfactant therapy in preterm neonates with respiratory distress.

Lung ultrasound is an accurate and early predictor for surfactant replacement therapy in respiratory distress syndrome (RDS) as compared to clinical parameters and chest x-ray. However, lung pathologies for respiratory distress at birth have overlapping symptomatology and low middle-income countries have a higher incidence of congenital pneumonia, in addition to RDS, making the immediate diagnosis difficult. Thus, there is a need for assessing a cutoff for lung ultrasound scores in the given setting. The primary objective was to determine the diagnostic accuracy of the lung ultrasound score (LUS) in predicting the need for surfactant therapy in preterm neonates with respiratory distress. Secondary objectives were to correlate LUS with corresponding oxygen saturation to the fraction of inspired oxygen ratio (SpO2/FiO2), arterial/Alveolar oxygen pressure ratio (a/A), and chest x-ray (CXR) findings. A prospective observational study was carried out at a tertiary-level neonatal intensive care unit in India in 2022 enrolling 100 neonates <34 weeks gestational age with respiratory distress at birth. After initial stabilization of the neonate, LUS was performed and baseline parameters were noted. Surfactant was administered as per the 2019 European Consensus guidelines and LUS was repeated after 6 h of therapy. The mean gestation of enrolled neonates was 31.06 ± 2.12 weeks and the mean birthweight was 1,412 ± 391 g. Approximately 58% were diagnosed with RDS and 30% had congenital pneumonia. Surfactant was administered to 40% of neonates. The cutoff LUS for surfactant therapy was 7 [area under the curve (AUC) 0.977; 95% CI, 0.947-1; P < 0.001; with sensitivity 92.5%, specificity 96.67%, PPV 94.87%, and NPV 95.08%] and the cutoff LUS for the second dose of surfactant was 10 (AUC 0.964; 95% CI, 0.913-1; P < 0.001). The score decreased by 3.24 (2.44-4.05) after 6 h of the first dose and correlated significantly with SpO2/FiO2 ratio (-0.750), a/A ratio (-0.650), and CXR findings (0.801). The study predicted an optimal LUS cutoff of 7 and 10 for the need for the first dose of surfactant and re-treatment, respectively, in neonates <34 weeks gestational age with respiratory distress.

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.

Long-Term Neurodevelopmental Impairment among Very Preterm Infants with Sepsis, Meningitis, and Intraventricular Hemorrhage

Introduction: Sepsis and intraventricular hemorrhage (IVH) are associated with poorer long-term neurodevelopmental outcomes in very preterm infants (VPIs), but less is known about the long-term effect of meningitis and the combined impact of both meningitis and IVH. Our objective was to examine the long-term neurodevelopmental outcomes of VPIs with late onset sepsis and meningitis, with and without IVH, in Canada. Methods: We conducted a retrospective cohort study of all infants Results: Of the 6,322 infants in the cohort, 4,575 had no infection, 1,590 had late onset culture-positive bloodstream infection (CPBSI) only, and 157 had late onset meningitis. There was a significant (p Conclusion: There was an increasing trend of adverse neurodevelopmental outcomes when infants with no infection, late onset CPBSI and late onset meningitis are compared. IVH had an additive effect.

Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants

The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified. To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age. Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022. Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment. The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years. Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]). In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life. anzctr.org.au Identifier: ACTRN12611000916943.

The Clinical Characteristics, Microbiology and Risk Factors for Adverse Outcomes in Neonates with Gram-Negative Bacillary Meningitis.

Background: We aimed to describe the clinical features of Gram-negative bacillary (GNB) meningitis in neonates and investigate the risk factors associated with final adverse outcomes of neonatal GNB meningitis. Methods: From 2003 to 2020, all neonates (aged ≤ 90 days old) with bacterial meningitis who were hospitalized in four tertiary-level neonatal intensive care units (NICUs) of two medical centers in Taiwan were enrolled. Neonates with GNB meningitis were compared with those with Streptococcus agalactiae (group B streptococcus, GBS) meningitis. Results: During the study period, a total of 153 neonates with bacterial meningitis were identified and enrolled. GNB and GBS accounted for 40.5% (n = 62) and 35.3% (n = 54) of all neonatal bacterial meningitis, respectively. In neonates with GNB meningitis, the final mortality rate was 6.5% (4 neonates died); 48 (77.4%) had neurological complications, and 26 (44.8%) of 58 survivors had neurological sequelae at discharge. Although the final outcomes were comparable between neonates with GNB meningitis and those with GBS meningitis, neonates with GNB meningitis were more likely to have more severe clinical manifestations initially and have ventriculomegaly at follow-up. After multivariate logistic regression analysis, neonates with seizure at onset, early onset sepsis, and requirement of surgical intervention for neurological complications were independently associated with final adverse outcomes. Conclusions: GNB meningitis was associated with a high risk of neurological complications and sequelae, although it did not significantly increase the final mortality rate. Close monitoring of the occurrence of neurological complications and advanced therapeutic strategies to optimize the outcomes are urgently needed in the future.

Effect of Maternal Coronavirus Disease on Preterm Morbidities.

Coronavirus disease (COVID-19) during pregnancy may have an impact on preterm morbidities due to the inflammatory nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Exposure to intrauterine inflammation could result in adverse consequences in preterm infants. We aimed to determine the effect of maternal coronavirus disease on preterm morbidities at a tertiary neonatal intensive care unit. This observational cohort study compared the clinical outcomes of preterm infants < 37 gestational weeks with and without maternal COVID-19. The study was conducted in a tertiary-level neonatal intensive care unit between March 2020 and December 2021. Demographics and clinical data of the study groups were collected from the medical files. A total of 254 infants (127 in the maternal COVID-19 group and 127 in the control group) were included in the study. Respiratory distress syndrome, early and late neonatal sepsis, intraventricular hemorrhage, patent ductus arteriosus (PDA), necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity rates were similar between groups. In the subgroup analysis, the rate of PDA was significantly higher in preterm infants ≤1,500 g with maternal SARS-CoV-2 infection (38 vs. 15% p = 0.023). Presence of maternal COVID-19 was found to be an independent predictor for PDA in very low birthweight infants, as revealed by multivariate analyses (odds ratio: 3.4; 95% confidence interval: 1.12-10.4; p = 0.031). Mortality rates and duration of hospitalization were similar in both groups. Our results suggest that COVID-19 infection during pregnancy seems to have no adverse effect on preterm morbidities and mortality. However, maternal COVID-19 was found to be a risk factor for PDA in preterm infants ≤1,500 g. · The effect of maternal COVID-19 on preterm morbidities still has not well defined.. · Maternal COVID-19 seems to have no adverse effect on preterm morbidities and mortality.. · The exact impact of the COVID-19 on fetal/neonatal health is yet to be clarified..

Experiences of Mothers of Preterm Infants in the Neonatal Intensive Care Unit During the COVID-19 Pandemic.

The neonatal intensive care unit (NICU) stay following the birth of a preterm infant can be stressful and traumatic for families. During the COVID-19 pandemic, the NICU environment changed precipitously as infection control and visitor restriction measures were implemented. Our study aimed to examine the impact of the pandemic policies on the experiences of mothers of preterm infants during their stay in the NICU. Semistructured interviews were conducted with mothers of preterm infants hospitalized in a Canadian tertiary-level NICU. Informed by interpretive description methodology, interview content was transcribed and analyzed using a thematic analysis approach. The identified themes were validated, clarified, or refined using investigator triangulation. Nine English-speaking mothers, aged 28 to 40 years, were interviewed. Four themes emerged from the analysis of their experiences: (1) disrupted family dynamic, support, and bonding; (2) physical and emotional isolation; (3) negative psychological impact compounded by added concerns, maternal role change, and survival mode mentality; and (4) positive aspects of the pandemic management measures. During the pandemic, the way that care was provided in the NICU changed. This study helps to explore how neonatal clinicians can foster individual and organizational resilience to keep patients and families at the center of care, even when the healthcare system is under intense stress. : Our results show that these changes heightened mothers' distress, but also had a modest positive impact. Further research about long-term consequences of pandemic policies on the mother and preterm infant after NICU discharge is warranted.

Characteristics of Children With Cerebral Palsy in the Post-Therapeutic Hypothermia Era.

Objectives: To explore the profile of children with cerebral palsy secondary to intrapartum asphyxia treated with therapeutic hypothermia after birth and to compare characteristics of children treated with therapeutic hypothermia with mild vs severe cerebral palsy outcome. Study Design: We identified all children treated with therapeutic hypothermia for intrapartum asphyxia in a single-center tertiary-level neonatal intensive care unit from 2008 to 2018 with a cerebral palsy outcome. We collected perinatal and outcome measures from patient charts. We searched the literature for characteristics of children with cerebral palsy prior to therapeutic hypothermia (historical cohort) to compare to our cohort. We subdivided our cohort into mild vs severe cerebral palsy and compared neonatal characteristics to identify predictors of severe phenotype. Results: Thirty of 355 cooled neonates (8%) developed cerebral palsy. More children had spastic quadriparesis and epilepsy, and fewer had visual impairment in the post-therapeutic hypothermia era compared to the historical cohort, but had similar Gross Motor Function Classification System scores. In our cohort, more children had severe (19 of 30, 63%) compared to mild cerebral palsy (11 of 30, 37%). The severe group had higher mean birth weight, lower 5- and 10-minute Apgar scores, and more often white matter injury with associated deep gray matter injury or near-total injury pattern (P < .05). Conclusions: Our data demonstrated more infants with severe rather than mild cerebral palsy in our cohort treated with therapeutic hypothermia. Birthweight, 5- and 10-minute Apgar scores, and magnetic resonance imaging (MRI) findings were significantly different between mild and severe phenotype groups. Our findings can guide clinicians how to better weigh these factors, when counseling parents in the neonatal period.

Evaluating the Use of Neonatal Colonization Screening for Empiric Antibiotic Therapy of Sepsis and Pneumonia

(1) Background: Since 2013, weekly screening for multidrug-resistant Gram-negative (MDRGN) bacteria has been performed in German neonatal intensive care units (NICU). National guidelines recommend considering these colonization analyses for antibiotic treatment regimens. Our retrospective single center study provides insight into the clinical dichotomy of bacterial colonization and infection rates in neonates. (2) Methods: We analyzed microbiological data of neonates admitted to our tertiary level NICU over nine years. Colonization with MDRGN/Serratia marcescens (SERMA) was compared to microbiological findings in sepsis and pneumonia. (3) Results: We analyzed 917 blood and 1799 tracheal aspirate samples. After applying criteria from the Nosocomial Infection Surveillance for Neonates (NEO-KISS), we included 52 and 55 cases of sepsis and pneumonia, respectively; 19.2% of sepsis patients and 34.5% of pneumonia patients had a prior colonization with MDRGN bacteria or SERMA. In these patients, sepsis was not attributable to MDRGN bacteria yet one SERMA, while in pneumonias, ten MDRGN bacteria and one SERMA were identified. We identified late-onset pneumonia and cesarean section as risk factors for MDRGN/SERMA acquisition. (4) Conclusions: Colonization screening is a useful tool for hygiene surveillance. However, our data suggest that consideration of colonization with MDRGN/SERMA might promote extensive use of last resort antibiotics in neonates.

Combination therapy for patent ductus arteriosus in preterm infants: Echocardiographic changes and clinical use

BackgroundSearching for the optimal therapeutic strategy for hemodynamically significant Patent Ductus Arteriosus in preterm infants is ongoing. A novel approach utilizing a combination of ibuprofen and acetaminophen has generated interest, with speculations that this approach may be more effective than standard single-agent therapy. ObjectivesOur objectives were to compare the echocardiographic parameters before and after the combination therapy and to describe its use (primary vs. rescue), effectiveness, and side effects. MethodsThis was a retrospective cohort review of preterm infants born <33 weeks gestation who were admitted to a tertiary-level neonatal intensive care unit between January 1, 2012, and December 31, 2020. Included infants received combination pharmacotherapy with ibuprofen and acetaminophen for ductal closure, either as a primary course (1st line use) or as a rescue (2nd or 3rd course), and had echocardiographic measurements pre-and post-therapy. Baseline characteristics, echocardiographic parameters of ductus arteriosus hemodynamics before and after combination therapy, the effectiveness of treatment, and adverse effects were examined. ResultsDuring the study period, 32 infants received combination therapy, with 17 (53 %) receiving it as a primary course and 16 (47 %) receiving it as a rescue course after trying another pharmacological agent. Complete echocardiographic data were available for 17 infants included in the study (11 primary and 6 rescues). The overall treatment success rate was 41 %. The primary course had a better treatment success rate (55 %) than the rescue course (17 %). Echocardiographic analysis showed that the primary course treatment resulted in significantly lower ductal diameter (p = 0.013), higher ductal flow Doppler velocities (p = 0.037), more restrictive shunt pattern (p = 0.005), and decreasing ductus arteriosus significance score (p = 0.016). Such improvement in hemodynamic significance was not noted when combination therapy was used as rescue therapy. ConclusionPrimary combination therapy with ibuprofen and acetaminophen resulted in considerable improvements in echocardiographic markers of hemodynamically significant ductus arteriosus. Future trials exploring the safety and efficacy of this treatment as a first-line option are required.

Risk Factors for Mortality From Late-Onset Sepsis Among Preterm Very-Low-Birthweight Infants: A Single-Center Cohort Study From Singapore.

ObjectiveTo determine the risk factors for mortality associated with late onset sepsis (LOS) among preterm very-low-birthweight (VLBW) infants.Study DesignWe performed a retrospective cohort study of infants born <32 weeks gestation and <1,500 gm admitted to a Singaporean tertiary-level neonatal intensive care unit. We determined the clinical, microbial, and laboratory risk factors associated with mortality due to culture-positive LOS in this cohort.ResultsA total of 1,740 infants were admitted, of which 169 (9.7%) developed LOS and 27 (16%) died. Compared to survivors, those who died had lower birth gestational age (median 24 vs. 25 weeks, p = 0.02) and earlier LOS occurrence (median 10 vs. 17 days, p = 0.007). There was no difference in the incidence of meningitis (11.1 vs. 16.9%, p = 0.3), NEC (18.5 vs. 14.8%, p = 0.6), or intestinal surgery (18.5 vs. 23.3%, p = 0.6) among infants who died compared to survivors. Gram-negative bacteria accounted for 21/27 (77.8%) LOS-associated deaths and almost all (13/14, 93%) fulminant episodes. The presence of multiorgan failure, as evidenced by the need for mechanical ventilation (100 vs. 79.0%, p = 0.008), elevated lactate (12.4 vs. 2.1 mmol/L, p < 0.001), and inotropic support (92.6 vs. 37.5%, p < 0.001), was significantly associated with mortality. Infants who died had significantly lower white blood cell (WBC) counts (median 4.2 × 109/L vs. 9.9 × 109/L, p = 0.001), lower platelet count (median 40 × 109/L vs. 62 × 109/L, p = 0.01), and higher immature to total neutrophil (I: T) ratio (0.2 vs. 0.1, p = 0.002). Inotrope requirement [AOR 22.4 (95%CI 2.9, 103.7)], WBC <4 × 109/L [AOR 4.7 (1.7, 13.2)], and I: T ratio >0.3 [AOR 3.6 (1.3, 9.7)] were independently associated with LOS mortality.ConclusionsIn a setting with predominantly Gram-negative bacterial infections, the need for inotropic support, leukopenia, and elevated I: T ratio were significantly associated with LOS mortality among preterm VLBW infants.

Impact of psychological distress and psychophysical wellbeing on posttraumatic symptoms in parents of preterm infants after NICU discharge

BackgorundParents after Neonatal Intensive Care Unit (NICU) hospitalization of preterm infant may develop psychopathological symptoms.The aim of the study was to determine how parental stress and psychophysical wellbeing affect posttraumatic symptoms (PTTS) in parents during the first year after NICU discharge. Moreover, this study aimed to explore any gender-specific difference in psychological distress among mothers and fathers.MethodsProspective study design from September 2018 to September 2019. 20 pairs of parents of preterm infants admitted to a tertiary-level NICU were enrolled. Primary outcome was evaluation of PTTS in parents of preterm infants at one year after NICU discharge through Impact of Event Scale- Revised. Secondary outcomes were: impact of parental stress, psychophysical wellbeing, anxiety and depression respectively through Parental Stressor Scale: NICU, Short Form Health Survey-36(SF-36), Self-rating Anxiety Scale and Self-rating Depression Scale.ResultsMothers experienced higher rates of PTTS than fathers across the first year after NICU discharge (55% vs 20%). Maternal avoidance symptoms were associated with perception of their own infant look. Emotional aspects linked to maternal role predicted 36,8% of their hyperarousal symptoms. Maternal PTTS severity was predicted by their social functioning. Paternal mental health was associated both with maternal and paternal intrusive symptoms.. Maternal stress was associated with paternal avoidance symptoms. Paternal mental health predicted their hyperarousal symptoms (40%) and PTSD severity (52%).ConclusionsParents who experienced NICU hospitalization of their own infant are at heightened risk to develop psychopathological symptoms. According to our initial hypothesis, investigating parental psychophysical wellbeing, through SF-36, originally provides a valuable support to detect parents at higher risk to develop posttraumatic outcomes across the first year after NICU discharge. In addition, paternal depression deserves to be taken into account since hospitalization as it could impact paternal PTSD development. Finally, these findings provide an initial evidence of gender-related patterns in PTSD development and psychological distress among mothers and fathers across the first year of their infant.

Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome

The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain. To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD). Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020. Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met. The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately. Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group. Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded. anzctr.org.au Identifier: ACTRN12611000916943.

Diagnostic Role of Systemic Inflammatory Indices in Infants with Moderate-to-Severe Hypoxic Ischemic Encephalopathy.

When the newborn brain is exposed to hypoxia, as in hypoxic ischemic encephalopathy (HIE), it causes an inflammatory response. A wide variety of inflammatory markers are therefore used in the diagnosis of HIE. We aimed to determine the diagnostic role of systemic inflammatory indices in infants with moderate-to-severe HIE. We have also investigated the effect of hypothermia treatment over those indices. A retrospective cohort study of infants suffering from moderate-to-severe HIE was conducted in a tertiary-level neonatal intensive care unit between September 2019 and March 2021. Systemic inflammatory indices including systemic immune-inflammation index (SII), pan-immune-inflammation value (PIV), systemic inflammation response index (SIRI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) were calculated for infants with HIE and controls at baseline, and after therapeutic hypothermia in those with HIE. A total of 103 infants (53 in the HIE group and 50 in the control group) were included in the study. Median gestational ages (GA) were 39 (37-40) and 38 (37-39) weeks, and median birth weights (BW) were 3,165 (2,890-3,440) and 3,045 (2,850-3,460) g in the HIE and control groups, respectively. GA, BW, mode of delivery, and gender of infants were similar between the groups. Infants in the HIE group had significantly higher NLR (p = 0.001), SII (p = 0.001), PIV (p = 0.001), and SIRI (p = 0.004) values when compared with the control group. Those indices decreased significantly after hypothermia treatment in the HIE group. Areas under curve for NLR, PLR, MLR, SII, SIRI, and PIV to predict HIE were found to be 0.808, 0.597, 0.653, 0.763, 0.686, and 0.663, respectively. Cutoff values having a good ability to predict HIE for SII and NLR were 410 and 1.12. Elevated NLR level above 1.12 was found to be an independent predictor for HIE, as revealed by multivariate analyses. No associations were found between systemic inflammatory indices and amplitude-integrated electroencephalography (aEEG) patterns, presence of seizures, and death. Systemic inflammatory indices may represent reliable and readily available predictors of HIE risk. NLR seems to be an independent factor in diagnosing moderate-to-severe HIE. · Systemic inflammatory incides are readily calculated from the peripheral blood count.. · NLR is an independent and valuable factor in diagnosing moderate-to-severe hypoxic-ischemic encephalopathy.. · Systemic inflammatory incides might be feasible for diagnosing hypoxic-ischemic encephalopathy..