Health economic evaluation of CDC s recommendation (1996 and 2002) for prevention of early onset group B streptococcal disease in Thailand

Background: Group B streptococcus (GBS) infection is one of the leading causes of morbidity and mortality in the neonatal period in the USA. The Centers for Disease Control and Prevention (CDC) issued a recommendation to prevent early-onset GBS infection in 1996 and a revised recommendation in 2002. Objectives: To perform a health economic analysis of the CDC recommendation using clinical data currently available in Thailand. Study design: Health economic analysis. Materials and Methods: After reviewing the literature regarding clinical data I Thailand, a decision analysis was performed to evaluate the outcomes of 3 strategies: universal culture screening, intrapartum risk factors assessment, and no prevention. Outcomes: The medical care cost for each strategy and incremental medical care cost for the prevention of one GBS case were analyzed. Results: Under the present conditions in Thailand and using the cost estimated from Siriraj Hospital’s charge in the year 2005, the no prevention practice was the most cost-effective strategy. The incremental medical care cost to prevent one GBS case for the universal culture screening and the intrapartum risk assessment were 594,754.17 Baht and 83,677.78 Baht, respectively. Conclusion: Although neither of the preventive strategies recommended by the CDC was cost-effective in general clinical practice in the present situation in Thailand, the intrapartum risk assessment strategy may be reasonable because the incremental cost to prevent one GBS case was less than 100,000 Baht.

Predictive values of serial C-reactive protein in neonatal sepsis.

BACKGROUND: Infection is one of the major problems in neonates. The diagnosis of neonatal septicemia is difficult to establish based on the clinical criteria alone. However, empirical treatment should not be delayed because of the high mortality. Laboratory tests used to support diagnosis have shown variable predictive values. C-reactive protein (CRP), an acute phase protein, increases in inflammatory disorders and tissue injury. Serial CRP have been shown to be more useful than a single measured CRP in the diagnostic evaluation of neonates with suspected infection. OBJECTIVES: 1. To evaluate the diagnostic accuracy of serial CRP in neonatal sepsis. 2. To compare the diagnostic values between CRP and leukocyte index from a complete blood count (CBC). METHOD: A prospective observational study included newborn infants, aged > 3 days and diagnosed with clinical sepsis, who were admitted in the newborn intensive care unit and special care nursery at Ramathibodi Hospital during a 14-months period. Newborn infants who received antibiotics prior to septic work up were excluded. CRP levels were measured initially at the time of septic work-up and at 24-48 hours later. Investigations for infection included CBC, blood culture and urine culture. Radiological study and lumbar puncture were performed if clinically indicated. Based on clinical and biological data, diagnosis of infants can be categorized into 4 groups as follows; (1) proven sepsis with positive culture, (2) localized infection with negative culture, (3) probable infection (clinically consistent with sepsis, negative culture without localized infection), and (4) no infection (findings not consistent with sepsis and antibiotics were discontinued within 3 days). Diagnosis was made before the CRP results were known. RESULTS: Of 76 newborn infants with 90 episodes of clinical sepsis, there were 24 episodes of proven sepsis, 11 episodes of localized infection with negative culture, 18 episodes of probable infection and 37 episodes of no infection. Serial CRP had better predictive values than those of CBC. The sensitivity, specificity, positive predictive value, and negative predictive value of CRP for proven sepsis and localized infection at cutoff point > or = 5 mg/L were 100 per cent, 94 per cent, 91.6 per cent and 100 per cent respectively. False positive CRP were found in post-operative patent ductus arteriosus ligation, intracerebral hemorrhage, and post resuscitation with chest compression. To improve the predictive value of CBC, analysis of the receiver operating characteristic (ROC) curve showed that the predictive value of CBC for sepsis would be enhanced by using abnormal leukocyte index 2 2 parameters. CONCLUSIONS: Predictive value of CRP could be enhanced by serial rather than a single measurement. Serial CRP showed very high predictive values for diagnosis of neonatal sepsis and were better than those of leukocyte indices of CBC.

Neurobiologic risk score and long-term developmental outcomes of premature infants, birth weight less than 1,250 grams.

OBJECTIVE: To determine whether neurobiologic risk score (NBRS) would continue to correlate with developmental outcomes. METHOD: An observational cohort consisting of 258 surviving infants who returned to the follow-up clinic with a mean age 22 months' corrected age. Both univariate and multivariate analysis were performed to identify risk factors and to assess the predictive value of NBRS. RESULTS: Forty-eight to 53 per cent of these infants had growth parameters < 25th percentile for age. Seventeen and 18 per cent respectively had mental developmental index (MDI) and psychomotor developmental index (PDI) on the Bayley Scales less than 70 and 14 per cent developed cerebral palsy (CP). NBRS demonstrated a significant correlation with the outcome (p < 0.001). In infants with NBRS > or = 8, 48 per cent had MDI < 70 and 68 per cent, had PDI < 70. At a similar NBRS cutoff, specificity and negative predictive value (NPV) were 86 and 96 per cent, respectively. Logistic regression indicated that birth weight and gestational age were the most significant, independent variables for predicting poor outcomes. CONCLUSION: Very preterm infants in the present study were at risk for abnormal developmental outcomes. NBRS demonstrated a very high specificity and NPV and may be a useful index to identify those who need early intervention.

Neonatal lupus erythematosus: clinical manifestations and management.

The authors report 6 cases of neonatal lupus erythematosus (NLE) who were seen at Ramathibodi Hospital from 1993 to 2000. The female to male ratio was 1:5. Cutaneous lesions were the major manifestation in all cases. Other clinical manifestations were thrombocytopenia, hepatosplenomegaly and mild elevation of liver enzymes. Skin rashes mostly erupted at 3-6 weeks old. None had a complete heart block but one had abnormal electrocardiograph (ECG) changes compatible with Wolff-Parkinson-White syndrome (WPW). Four of six patients had thrombocytopenia. All of the abnormalities resolved spontaneously except thrombocytopenia. Three of six needed blood transfusion to replace blood loss from gastrointestinal bleeding. Intravenous immunoglobulin (IVIG) 2 g/kg was given in 3 cases with good response in two of three cases. Platelets rose rapidly and maintained at a normal level within 24-48 hours. Combined therapy with corticosteroid 2 mg/kg was given to 1 case with good outcome. Telangiectasia was the most common sequelae especially in patients who had periorbital lesions resembling raccoon's eyes. The authors conclude that IVIG in the dose of 1 g/kg for 1-2 days is an effective treatment for NLE with severe thrombocytopenia especially when corticosteroid is contraindicated.

Oral erythromycin for treatment of feeding intolerance in preterm infants: a preliminary report.

Feeding intolerance is a common problem in preterm infants resulting in a prolonged hyperalimentation which is associated with an increased risk of serious and sometimes even life threatening complications, including cholestasis jaundice, liver impairment, nutritional deficiency, biochemical rickets and catheter-related septicaemia. Erythromycin, a commonly used macrolide antibiotic, has been reported as having potent prokinetic properties and enhancing gastrointestinal motor activity. The authors, therefore, conducted a preliminary study of oral erythromycin for the treatment of feeding intolerance in preterm infants to evaluate the safety and efficacy of this drug. AIM: To evaluate the safety and efficacy of oral erythromycin as a prokinetic agent in promoting enteral feeding in preterm infants with feeding intolerance. METHOD: Preterm infants, gestational age (GA) < or = 36 wk, who met the feeding intolerance criteria, were enrolled in the study. Inclusion criteria included infants who received enteral feeding less than half of full feeding or less than 75 ml/kg/day by day 14 post-natal age or gastric residual > or = 50 per cent of a given amount of feeding, more than 2 consecutive feeds by day 7 post-natal age. All patients received oral erythromycin ethylsuccinate 12 mg/kg every six hours for 2 days, then 3 mg/kg every six hours for 5 days. The times taken to establish full enteral feeding after the drug treatment and time to stop hyperalimentation were recorded. Potential adverse effects of erythromycin were assessed. Response to treatment was defined as decreased gastric residual < 30 per cent of a similar amount of the previous feed and was able to continue to full feeding. RESULTS: Ten preterm infants were enrolled in this study with a mean GA of 30.8 weeks (26-35), mean birth weight of 1,489 g (range 900-2,560 g) and mean age at entry of 9.2 days (range 7-12 days). Nine of 10 infants responded to treatment within 24 hours. The average time to establish full enteral feeding after the drug treatment was 6.6 days (range 4-10 days). None of the infants developed adverse effects such as vomiting, diarrhea, or pyloric stenosis. CONCLUSION: The preliminary data indicates that oral erythromycin is effective and safe in facilitating enteral feeding in preterm infants with feeding intolerance. Infants can achieve full feeding within a week after treatment, and this may shorten the course of hyperalimentaiton. Further randomized controlled trials are warranted.

Comparison of the effectiveness between the adapted-double phototherapy versus conventional-single phototherapy.

BACKGROUND: Jaundice is very common in neonates during the first few days of life. Severe hyperbilirubinemia is potentially neurotoxic, resulting in bilirubin encephalopathy. Phototherapy has been used widespread and proven to be effective in lowering serum bilirubin. The efficacy of phototherapy depends on the type of light-source, the intensity of light and the area of skin exposed. Double phototherapy with a fiber-optic blanket has been reported to be more effective in reducing bilirubin than conventional phototherapy. However, a fiber-optic blanket or bili-bed is very expensive, thus the authors designed the adapted-double phototherapy by using ordinary fluorescent lamps that are much cheaper and more easily available. OBJECTIVE: To compare the efficacy and safety of adapted-double phototherapy (DP) using daylight fluorescent lamps to conventional phototherapy (CP) in healthy term infants with hyperbilirubinemia. DESIGN: Prospective randomized controlled trial study. METHOD: Term infants who met phototherapy criteria were randomized into two groups of phototherapy; the adapted DP placing daylight fluorescent lamps 38 cm above and 32 cm below the crib to produce 9-10 microw/cm2/nm (n = 24) versus CP of similar irradiance (n = 27). RESULT: There were no significant differences between the two groups with respect to birth weight, gestational age, hematocrit at enrollment and cause of hyperbilirubinemia. Infants in the DP group had higher bilirubin levels and were slightly older at the time of enrollment than those in the CP group. The bilirubin reduction rate after therapy was significantly greater in the DP compared to CP; 0.22 +/- 0.12 mg/dl/h vs 0.14 +/- 0.1 mg/dl/h on day 1 of therapy (p = 0.02) and 0.16 +/- 0.11 mg/ dl/h vs 0.1 +/- 0.05 mg/dl/h on day 2 (p = 0.06). Duration of phototherapy was shorter in DP; 34.9 +/- 12.6 h vs 43.7 +/- 17.5 h in CP group (p = 0.039). No differences in side effects were found between two groups. CONCLUSION: The adapted-DP using daylight fluorescent lamps in this study has proven to be safe and more effective in reducing bilirubin than CP. It could be an alternative model for intensified phototherapy as it produces a reasonable cost-effectiveness and is easy to apply.