Effectiveness of simple strategies in reducing multidrug resistant blood stream infections in neonatal intensive care unit of tertiary care hospital in Karachi, Pakistan

To report reduction in transmission of multidrug resistant organisms from the neonatal intensive care unit after the implementation of simple risk-reduction strategies. Using a pre-and-post design, the study was carried out from June 2010 to December 2011 at the neonatal intensive care unit of Aga Khan University Hospital, Karachi, which is 12-bed, level III facility. The intervention comprised hand washing certification for all staff, use of chlorhexidine instead of povodine iodine for skin preparation, use of non-sterile gloves for diaper change, implementation of barrier nursing for clinically-suspected and culture-proven infections, provision of separate intubation and central line trolley for each room and limiting the use of umbilical catheters to 7 days. Data is reported for 3-month pre-intervention period, one-month implementation phase, and for 3-month post-intervention phase. Data for 12 months post-implementation is reported to show sustainability. The average pre intervention rates of bloodstream infections due to extended spectrum beta lactamase, Acinetobacter, Pseudomonas and methicillin resistant staphylococcus aureus were 4.7, 3.3, 1.2 and zero respectively. The average number of admissions during the 3 phases was almost similar [49, 46 and 53 respectively]. There was sustained reduction in rates for all organisms 12 months after the intervention period. Nosocomial transmission of multi drug resistant organisms within the neonatal intensive care unit can be effectively reduced by adopting simple strategies

Pneumothoraces in a neonatal tertiary care unit: case series

Neonatal pneumothoraces are associated with high mortality Prompt recognition to minimize its complications is paramount for ultimate outcome of these babies, A retrospective case series study was carried out at Aga khan University Hospital, from January 2010 to December 2010 to determine the etiology and outcome of neonates with pneumothorax in a neonatal tertiary care unit, Ten neonates diagnosed radiologically with pneumothoraces were included. M: F ratio was 1:2.3, Birth weight ranged from 1750-3600 grams with a mean of 2100 grams. The occurrence of pneumothoraces was 50% on the left side, 20% on right, and 30% were bilateral. Primary etiology included pneumonia and sepsis [30%], hyaline membrane disease [20%], meconium aspiration syndrome [20%] and congenital diaphragmatic hernia [10%], Spontaneous pneumothoraces were present in 20% of cases. In our study, the incidence of neonatal pneumothoraces was 2.5/1000 births compared to 10-15/1000 in Denmark, 10-20/1000 in Turkey and 6.3/1000 from Vermont Oxford Group Despite the small number of cases, one incidental finding was the occurrence of pneumothorax, which declined in elective cesarean section after 37 weeks gestation i.e., 1.3 of 1000 births. Mortality was 60% determined mainly by the primary etiology and other co-morbid conditions. The study showed a higher number of mortality cases [60%]. Although, it was difficult to draw a conclusion from the limited number of cases, there may be a benefit on neonatal respiratory outcome to be obtained by better selection of mothers and by waiting until 37 weeks before performing elective cesarean section. Adequate clinician training in soft ventilation strategies will reduce the occurrence of pneumothoraces

Salmonella cholecystitis: atypical presentation of a typical condition

Salmonella cholecystitis is a rare but important complication of Salmonella typhi infection. We are reporting an 11 years old female child who presented with complaints of high-grade fever, jaundice and right sided abdominal pain [Charcot's triad]. Her examination showed tender hepatomegaly. Initial blood results revealed high white cell counts with left shift, deranged liver function tests. Abdominal ultrasonography revealed distended gallbladder with minimal layer of sludge seen within its lumen along with streak of pericholecystic fluid. Blood culture grew Salmonella typhi. She was successfully treated with intravenous ceftriaxone.

Icterus neonatorum in near-term and term infants an overview

Neonatal jaundice is the yellowish discoloration of the skin and/or sclerae of newborn infants caused by tissue deposition of bilirubin. Physiological jaundice is mild, unconjugated [indirect-reacting] bilirubinaemia, and affects nearly all newborns. Physiological jaundice levels typically peak at 5 to 6 mg/dL [86 to 103 micro mol/L] at 72 to 96 hours of age, and do not exceed 17 to 18 mg/dL [291-308 micro mol/L]. Levels may not peak until seven days of age in Asian infants, or in infants born at 35 to 37 weeks' gestation. Higher levels of unconjugated hyperbilirubinaemia are considered pathological and occur in a variety of conditions. The clinical features and management of unconjugated hyperbilirubinaemia in healthy near-term and term infants, as well as bilirubin toxicity and the prevention of kernicterus, are reviewed here. The pathogenesis and aetiology of this disorder are discussed separately

Neonatal hypothermia among hospitalized high risk newborns in a developing country

To estimate the frequency of neonatal hypothermia and to identify the risk factors associated with it. This cross sectional survey study was conducted from March 2008 to November 2008 in the Neonatal Intensive Care Unit, Department of Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan. Data was collected with a pre tested data collection tool. Three hundred neonates were included in the study. SPSS v17.0 was used for descriptive analysis. Of the 300 neonates admitted to the neonatal unit, 144 [49.5%] developed hypothermia. The frequency of hypothermia was found to be significantly higher in low birth weight [LBW] 58.1% and preterm 64.2% babies. There is a high frequency of neonatal hypothermia in our setup which is on the higher side of the range reported in comparable regions. LBW and prematurity were independent risk factors as was the external environment at the time of delivery

Asthma in children management issues for family doctors

Asthma is still one of the leading causes of morbidity in children. Despite the improved understanding in the disease pathogenesis and availability of the different classes of drugs, the incidence of emergency visits due to acute exacerbations and admission rates due to frequent and uncontrolled disease is fairly high. Management of bronchial asthma in children is quite different to that of adults. Although there are universal guidelines available for the management of childhood asthma, there is still confusion especially among the family physicians who are largely involved in the management of the children, both in acute exacerbations as well as in long term prevention. This article aims to simplify all the management issues for family physicians in concurrence with the available asthma management guidelines

Newborn screening in Pakistan - lessons from a hospital-based congenital hypothyroidism screening programme

We are living in a time of unprecedented increase in knowledge and rapidly changing technology. Such biotechnology especially when it involves human subjects raises complex ethical, legal, social and religious issues. The establishment of newborn screening programmes in developing countries poses major challenges as it competes with other health priorities like control of infectious diseases, malnutrition and immunization programmes. Despite this, it is imperative that the importance of newborn screening programmes is recognised by developing countries as it has been proven through decades of experience that it saves thousands of babies from mental retardation, death and other serious complications. Pakistan has an estimated population of 167 million inhabitants, 38.3% of whom are under 15 years of age. Pakistan lacks a national programme for newborn screening. However, as individual practice at the local level, Aga Khan University Hospital (AKUH) and a few other hospitals are doing newborn screening for congenital hypothyroidism. The main hurdle in the implementation of newborn screening in Pakistan is the lack of good infrastructure for health. Eighty percent of deliveries take place at home. Moreover, little resources are available for children identified with a genetic condition due to the non-existence of genetic and metabolic services in Pakistan. In a 20-year audit of congenital hypothyroid screening at AKUH we found 10 babies with congenital hypothyroidism. However due to missing data links spanning several years, we were unable to calculate its true incidence during this period. In order to estimate the incidence of congenital hypothyroidism (CH) we reviewed in detail data over 10 months in 2008, a period where there was better compliance for repeat thyroid stimulating hormone (TSH) testing, and found 2 babies with CH. This gave an estimated incidence of 1 in 1600 live births.