Evaluating a Modified Use of the Kaiser Permanente Early-onset Sepsis Risk Calculator to Reduce Antibiotic Exposure: a Retrospective Study.

BACKGROUND: Early-onset neonatal sepsis (EONS) remains an important disease entity due to very serious adverse outcomes if left untreated. Lack of diagnostic tools in identifying healthy from diseased neonates, and clinicians' fear of the missing positive-culture sepsis babies, or babies with clinical sepsis have led to overtreating and unnecessary antibiotic exposure. Kaiser Permanente EONS risk calculator is an internally validated tool that can predict EONS. This sepsis risk calculator (SRC) classifies neonates into three subgroups: (1) ill-appearing, (2) equivocal and (3) well-appearing. We propose a modification to this tool that aims to use it solely for well-appearing babies. This modification represents a more conservative approach to decrease antibiotic exposure and offers an alternative for those hesitant to fully implement this tool. METHODS: This is a dual-centre retrospective study where data were extracted from the electronic medical records. Our primary outcome was to validate the modified use of the SRC with a two-by-two table. Specificity, negative predictive value and expected antibiotic reduction were used to evaluate the tool's feasibility. RESULT: Among 770 babies suspected of EONS, the feasibility of the modified use was tested. The expected antibiotic exposure reduction rate on the modification was 40.4% overall. The proposed modification resulted in a specificity and negative predictive value of 99.28% (95% CI: 97.92% to 99.85%) and 99.5% (95% CI: 99% to 99.8%), respectively. CONCLUSION: The modified use of the sepsis risk calculator has shown that it can safely reduce antibiotic exposure in well-appearing babies. The modified use is used as a 'rule out' test that can identify very low risk of EONS babies, and safely minimise antibiotic exposure. Further prospective studies are needed to examine the efficacy of this use, and quality improvement projects are required to evaluate its applicability in different clinical settings.

Elevated level of creatine phosphokinase in newborn: Clinical significance and association with congenital muscle diseases.

OBJECTIVES: To establish the normal Creatine phosphokinase (CPK) range in newborns of all 3 modes of delivery and prove that high CPK level in neonates is not specific a indicator for muscular pathology. METHODS: This is a prospective cohort study that is conducted in King Abdulaziz Medical City and King Abdullah Specialized Children Hospital in Riyadh and included 504 term neonates who were born between March 2021 and August 2021. Two hundred and fifty three were males and 251 were females. Data and consents were managed and collected using 2 coordinators. RESULTS: Duration of the second stage of labor, age on the first CPK test and fetal gestational age were significantly correlated with CPK values (r=0.197, r=-0.234, r=0.274, respectively). The normal ranges for each delivery type were 334 U/L-2667U/L in normal spontaneous vaginal delivery, 265U/L-1182U/L in elective cesarean section, and 223U/L-3082 U/L in emergency cesarean section. CONCLUSION: The CPK was elevated in all neonates in all 3 modes of deliveries. An elevated levels of CPK in neonates is not a specific indicator for any congenital muscular pathology.

Child mortality in Saudi Arabia: Time for action at all levels.

BACKGROUND AND OBJECTIVES: Although child mortality is declining in Saudi Arabia, new trends and causes are emerging. The objective of the study is to determine the causes of child death in a tertiary care hospital in Saudi Arabia and to identify its preventable causes and associated risk factors. METHODS: A modified UNICEF Multiple Indicator Cluster Survey (MICS) was used to analyze all deaths among children under the age of 18 which occurred at the King Abdullah Specialized Children's Hospital (KASCH) between 2010 and 2016. RESULTS: After reviewing all the death charts of 1138 children, the team determined that 15% (172) of all deaths could have been prevented and the preventability increased with age. Only 2% of the neonates died of preventable causes, while 53% of the children of 6 years of age or older died of preventable causes. The highest percentage of preventable deaths occurred in children aged 13-18 years (39.3%), followed by the age group of 6-12 years (32.4%) and the age group of 29 days to 5 years (13.9%). All 966 (85%) deaths from biological causes were considered to be unpreventable. Among the preventable causes, 142 (82.5%) had injuries and 30 (17.4%) were sudden unexpected infant death (SUID) with no documented autopsy or death scene investigation, and thus it was considered preventable by the researchers. The 5 major causes of deaths secondary to injuries were motor vehicle accidents (MVA) accounting for 86 deaths (60.6%), followed by drowning accounting for 19 deaths (13.4%), child maltreatment accounting for 13 deaths (9.2%), fire and weapon accounting for 12 deaths (8.5%), and finally home accident (fall, poisoning, suffocation) accounting for 12 deaths (8.5%). CONCLUSION: The State Child Death Reviews Board should thoroughly investigate deaths due to SUID and injuries by identifying the factors that contribute to the implementation of preventive strategies.

Framework for obstetrics and gynecology department change management in response to COVID-19 pandemic: A tertiary center experience.

Coronavirus (cov) disease 2019 pandemic caused by severe acute respiratory syndrome cov 2 has imposed significant demands on healthcare systems across the world. These demands were more significant on obstetrics and gynecology (obgyn) patients, who required services that had to continue despite the closure of other services. This paper describes the change management of an obgyn department at a tertiary health-care center. That experience resulted in a complete management shift in the institution and the formation of an infectious disease epidemic plan for respiratory infections. Description of the change management performed, difficulties encountered, and achievements obtained can assist other departments change management when they face similar situations.

Antimicrobial consumption in three pediatric and neonatal intensive care units in Saudi Arabia: 33-month surveillance study.

BACKGROUND: Despite their critical role in antimicrobial stewardship programs, data on antimicrobial consumption among the pediatric and neonatal population is limited internationally and lacking in Saudi Arabia. The current study was done as part of our antimicrobial stewardship activities. OBJECTIVES: To calculate overall and type-specific antimicrobial consumption. METHODS: A prospective surveillance study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between October 2012 and June 2015 in two pediatric and one neonatal intensive care units (ICUs). Consumption data were collected manually on a daily basis by infection control practitioners. Data were presented as days of therapy (DOT) per 1000 patient-days and as frequency of daily consumption. RESULTS: During the 33 months of the study, a total of 30,110 DOTs were monitored during 4921 admissions contributing 62,606 patient-days. Cephalosporins represented 38.0% of monitored antimicrobials in pediatric ICUs followed by vancomycin (21.9%), carbapenems (14.0%), aminoglycosides (8.8%), and piperacillin/tazobactam (8.8%). Their consumption rates were 265.1, 152.6, 97.6, 61.4, and 61.4 DOTs per 1000 patient-days (respectively). Aminoglycosides represented 45.4% of monitored antimicrobials in neonatal ICU followed by cephalosporins (30.4%) vancomycin (13.6%), and carbapenems (8.3%). Their consumption rates were 147.5, 98.7, 44.3, and 27 DOTs per 1000 patient-days (respectively). CONCLUSION: Cephalosporins are frequently used in pediatric ICU while aminoglycosides are frequently used in neonatal ICU. The local consumption of cephalosporins and carbapenems in both ICUs is probably higher than international levels. Such data can help in establishing and monitoring the functions of antimicrobial stewardship activities aiming to ensure judicious consumption of antimicrobials.

Neonatal Group B Streptococcal Infection in a Tertiary Care Hospital in Saudi Arabia: A 13-year Experience.

BACKGROUND: Group B streptococcus (GBS) is a leading cause of neonatal bacterial sepsis and meningitis globally. Studies concerning the incidence and burden of neonatal GBS disease in Saudi Arabia are lacking. This study determined the incidence and burden of GBS infection among neonates in association with maternal GBS screening. METHODS: A retrospective cohort chart review study included all neonatal GBS disease cases identified through microbiology lab records within the first 90 days of life in the hospital from January 2004 to December 2016. Charts were reviewed to collect maternal and neonatal characteristics using a standardized form. RESULTS: Over 13 years, of 108,609 live births, 55 GBS disease cases were identified (overall incidence, 0.51/1000 live births), 69.1% (n = 38) of those had early onset disease (EOD). The annual incidence in 2015 and 2016 was significantly higher than in any previous year (P < 0.0001), coinciding with the discontinuation of routine universal maternal GBS screening. Median age at presentation was 1 day (range, 0-54 days). We found that 67.3% (n = 37) of mothers were not screened antenatally, 72.9% (n = 27) of whom had neonates present with EOD. Neonates of unscreened mothers were more likely to have GBS disease (P = 0.01) and to present with EOD (P = 0.005). Urinary tract infection was the most common manifestation (47.3%, n = 26), followed by sepsis (43.6%, n = 24). Mortality rate was 3.6% (n = 2). CONCLUSIONS: The incidence of neonatal GBS infection in Saudi Arabia is similar to the worldwide incidence. Universal antenatal screening discontinuation was significantly associated with an increase in EOD incidence.

Intravitreal Ranibizumab Injection for the Treatment of Retinopathy of Prematurity.

OBJECTIVES: To evaluate the efficacy of a single injection of 0.3 mg intravitreal ranibizumab for the treatment of retinopathy of prematurity (ROP). METHODS: We conducted this retrospective case series study at King Abdul Aziz Medical City, Riyadh, Saudi Arabia. Seventy-four eyes of 37 preterm infants with ROP stage III with plus disease in zone I, posterior zone II, and aggressive posterior ROP received a single injection of 0.3 mg intravitreal ranibizumab. The favorable outcome measure was complete regression of the disease with normal vascularization of the retina of those infants. RESULTS: The gestational age of the 37 included cases was in the range of 23-28 weeks and their body weight at birth was between 510 and 1,235 g except for one case with 2,550 g under oxygen therapy <7days with severe hypoglycemia. All eyes showed a favorable response in terms of regression of plus disease from the first day after treatment, followed by regression of stage III retinopathy. All patients developed complete vascularization over variable periods of time. CONCLUSION: One injection of 0.3 mg intravitreal ranibizumab is effective in treating ROP stage III mainly in zones I and II.

Prospective study of early and late outcomes of extremely low birthweight in Central Saudi Arabia.

BACKGROUND: Survival of preterm neonates has steadily improved over the past five decades, due to changes in the neonatal intensive care. However, in Saudi Arabia, there are no written guidelines on the definition of the lower limit of viability, and there has been a call for such a limit. The aims of this study were: (1) to determine lower limits of viability and survival in extremely low birthweight (ELBW) infants, and (2) to determine incidence of neurodevelopmental and cognitive abnormalities within 3-6 years after birth. METHODS: Prospective study of all live inborn ELBW infants admitted to the neonatal unit of King Abdulaziz Medical City, Riyadh, Saudi Arabia, within 3 years [between January 1st, 2005 and December 31st, 2007] was conducted (n = 117). Data were collected on demographic and birth data, neonatal complications & interventions and death on discharge. Prospective follow up of all survivors was done, within 6 years after birth, to assess the outcome in terms of neurodevelopmental and cognitive abnormalities. Predictors of survival were determined using logistic regression model. Significance was considered at p-value ≤0.05. RESULTS: Of all ELBW infants, 41% died before discharge. Survival rate was directly correlated with gestational age (GA) and birthweight (p < 0.05). The 50% limits of viability were those at 25 weeks' gestation or with > 600 g. After adjusting for possible confounders, significant predictors of survival were birthweight (p = 0.001) and Apgar score (p < 0.001). The following impairments were reported during follow up of survivors: developmental delay (39.2%), cerebral palsy (36.2%), speech problems (33.3%), wasting (12.5%), intellectual disability (10%), visual problems (6.6%) and hyperactivity (5.6%). CONCLUSION: More than one-third of ELBW died before discharge from NICU, and two-thirds of survivors had one or more neurodevelopmental and/or cognitive abnormalities during their first 6 years of life. The 50% limits of viability of ELBW infants were those at week 25 of gestation or with a birthweight of more than 600 g. Birthweight could be considered as more valid than gestational age in the prediction of viability of ELBW infants. The process of care of ELBW infants in Saudi Arabia may need to be revisited taking these findings into consideration.

Expanded Newborn Screening Program in Saudi Arabia: Incidence of screened disorders.

AIM: To address the implementation of the National Newborn Screening Program (NBS) in Saudi Arabia and stratify the incidence of the screened disorders. METHODS: A retrospective study conducted between 1 August 2005 and 31 December 2012, total of 775 000 newborns were screened from 139 hospitals distributed among all regions of Saudi Arabia. The NBS Program screens for 16 disorders from a selective list of inborn errors of metabolism (IEM) and endocrine disorders. Heel prick dry blood spot samples were obtained from all newborns for biochemical and immunoassay testing. Recall screening testing was performed for Initial positive results and confirmed by specific biochemical assays. RESULTS: A total of 743 cases were identified giving an overall incidence of 1:1043. Frequently detected disorders nationwide were congenital hypothyroidism and congenital adrenal hyperplasia with an incidence of 1:7175 and 1:7908 correspondingly. The highest incidence among the IEM was propionic acidaemia with an incidence rate of 1:14 000. CONCLUSION: The article highlights the experience of the NBS Program in Saudi Arabia and providing data on specific regional incidences of all the screened disorders included in the programme; and showed that the incidence of these disorders is one of the highest reported so far world-wide.

Risk factors for isolated periventricular leukomalacia.

Periventricular leukomalacia, a major cause of neurologic disabilities in preterm infants, can be isolated or associated with intraventricular and periventricular hemorrhage. To determine the risk factors for isolated periventricular leukomalacia, we retrospectively studied the characteristics of all very low birth weight infants affected by isolated periventricular leukomalacia who were delivered over a 5-year period and compared them with a control group of very low birth weight infants, matched within 2 weeks for gestational age, with no central nervous system pathology, and born during the same period. In total, 20 affected infants were compared with 98 control infants. Neonatal sepsis caused by coagulase-negative Staphylococcus (P = 0.014) and neonatal seizure (P = 0.026) were associated with isolated periventricular leukomalacia only on univariate analysis. Three variables demonstrated statistically significant associations with isolated periventricular leukomalacia on both univariate and multivariate logistic regression analysis as independent risk factors: birth weight (odds ratio, 4.31; 95% confidence interval, 1.54-12.06; P = 0.005), early neonatal hypotension requiring combined inotropic therapy (odds ratio, 4.90; 95% confidence interval; 1.22-19.68, P = 0.025), and delayed surgical closure of hemodynamically significant patent ductus arteriosus beyond age 7 days (odds ratio, 1.20; 95% confidence interval, 1.06-1.35; P = 0.003).

CO(2) inhalation as a treatment for apnea of prematurity: a randomized double-blind controlled trial.

OBJECTIVE: To compare the effect of prolonged inhalation of a low concentration of CO(2) with theophylline for the treatment of apnea of prematurity. STUDY DESIGN: Prospective, randomized, double-blind controlled trial of 87 preterm infants with apnea of prematurity (27-32 weeks' gestational age) assigned to either theophylline plus 0.5 L/min of room air via nasal prongs or placebo plus 0.5 L/min with CO(2) (about 1% inhaled) by nasal prongs for 3 days. RESULTS: Apnea time significantly decreased in the theophylline group from 189±33 s/h (control) to 57±11, 50±9, and 61±13 (days 1-3) (P=.0001) and in the CO(2) group from 183±44 (control) to 101±26, 105±29, and 94±26 s/h (days 1-3) (P=.03). Seven infants in the CO(2) group but none in the theophylline group failed to complete the study due to severe apneas (P=.003). CONCLUSIONS: Because theophylline was more effective in reducing the number and severity of apneas, inhalation of low concentration of CO(2), as used in the present study, cannot be considered as an alternative to theophylline in the treatment of apnea of prematurity. The less effectiveness of CO(2) treatment may have been related to the variability of the delivery of CO(2).

Perioperative course of pulmonary hypertension in infants with congenital diaphragmatic hernia: impact on outcome following successful repair.

BACKGROUND: Pulmonary hypertension (PH) associated with congenital diaphragmatic hernia (CDH) remains a significant cause of morbidity and mortality. For improved outcomes, preoperative stabilization is commonly practiced to control the PH in infants with CDH. Some CDH infants who have been considered stabilized and ready for surgery have nevertheless developed significant PH after surgical repair. In fact, the markers and consequences of the preoperative stabilization are still unclear. Therefore, we examine the perioperative course of PH to evaluate the impact of preoperative PH severity on mortality and morbidity of infants who underwent surgical repair of CDH. METHODS: The medical charts of all newborns (n = 49) with CDH who were treated at our institution between January 2000 and December 2009 were reviewed. General management and perioperative data were evaluated for all infants. The ratio of estimated pulmonary artery pressure to systemic pressure (P/S ratio or PSR), based on echocardiographic data, was used to assess the PH severity during the perioperative period. RESULTS: The overall survival rate in our group of infants with CDH was 71.4%. Of the 49 infants with CDH, 9 (18.4%) died during the preoperative phase. Forty infants underwent CDH repair at a median age of 3.5 days (range, 1-46 days). Five of these infants (12.5%) subsequently deteriorated and died after surgery. Using receiver operating characteristic curve analysis, a PSR cutoff value before surgery of 0.9 predicted mortality in CDH infants with a sensitivity of 100% and specificity of 84% and with an area under the curve of 0.93 (P = .002). Accordingly, 2 groups of infants with distinct outcomes were identified, as follows: a low-PSR cohort (PSR ≤0.9) with a survival rate of 100% and a high-PSR cohort (PSR >0.9) with a survival rate of 50% (P = .001). The rate of pneumothorax and the frequency of use of several inotropic agents after surgery were significantly higher in the high-PSR group (P = .001 and .007, respectively). Compared with low-PSR infants, infants with high PSR were operated on later (P = .03) and were postoperatively ventilated longer (P = .01). During the entire perioperative period, significant differences in the PH severity were noted between the 2 PSR groups. During the first week of life, infants in the high-PSR group had significantly higher PSRs than those in the low-PSR group (P = .001); and similar tendencies continued to be significant between the 2 groups after CDH repair (P = .04). CONCLUSIONS: During the perioperative period, PH severity monitoring via the serial assessment of PSR is beneficial. Better outcomes were observed with a preoperative PSR less than or equal to 0.9, and this association needs to be confirmed by prospective study.

Can Doppler sonography be used to diagnose neonatal cerebral infarction caused by portal vein thrombosis.

Neonatal cerebral infarction is a serious and disabling condition. It is extremely rare if it occurs in association with portal vein thrombosis. We are reporting 2 cases of neonatal cerebral infarction with this etiology. The unique mechanism of cerebral infarction will be discussed. We propose that in the absence of any identifiable cause for the cerebral infarction, portal vein thrombosis should be considered and a Doppler sonography for the portal system is worth carrying out to confirm the diagnosis.

A randomized controlled trial of theophylline versus CO2 inhalation for treating apnea of prematurity.

OBJECTIVE: To determine whether inhalation of 0.8% CO(2) in preterm infants decreases the duration and rate of apnea as effectively as or better than theophylline with fewer adverse side effects. STUDY DESIGN: A prospective, randomized, control study of 42 preterm infants of gestational age 27 to 32 weeks assigned to receive inhaled CO(2) (n = 21) or theophylline (n = 21). The study group had a mean (+/- standard error of the mean) birth weight of 1437 +/- 57 g, gestational age of 29.4 +/- 0.3 weeks, and postnatal age of 43 +/- 4 days. After a control period, 0.8% CO(2) or theophylline was given for 2 hours, followed by a recovery period. RESULTS: In the CO(2) group, apneic time and rate decreased significantly, from 9.4 +/- 1.6 seconds/minute and 94 +/- 15 apneic episodes/hour to 3.0 +/- 0.5 seconds/minute and 34 +/- 5 apneic episodes/hour. In the theophylline group, apneic time and rate decreased significantly, from 8 +/- 1 seconds/minute and 80 +/- 8 apneic episodes/hour to 2.5 +/- 0.4 seconds/minute and 28 +/- 3 apneic episodes/hour. Cerebral blood flow velocity (CBFV) decreased only during theophylline administration. CONCLUSIONS: Our findings suggest that inhaled low (0.8%) CO(2) concentrations in preterm infants is at least as effective as theophylline in decreasing the duration and number of apneic episodes, has fewer side effects, and causes no changes in CBFV. We speculate that CO(2) may be a better treatment for apnea of prematurity than methylxanthines.

Prostaglandins are responsible for the inhibition of breathing observed with a placental extract in fetal sheep.

We have previously observed that the infusion of a placental extract inhibits breathing movements in fetal sheep, suggesting that a placental factor may be responsible for the inhibition of fetal breathing. Our preliminary results suggested that a small peptide or a substance bound to a peptide was likely responsible for this inhibition. Since prostaglandins are found in high concentrations in the placenta, it is possible that they may be responsible for the inhibition of breathing observed with the placental extract. We hypothesized that if prostaglandins were the active factors in the placental extract, then inhibition of the production of placental prostaglandins should eliminate the activity of the extract. We infused untreated and indomethacin/ASA-treated placental extracts into the carotid artery of eight chronically instrumented fetal sheep continuously over 3 h. The concentration of all prostaglandins measured in the untreated placental extracts were significantly higher than in the indomethacin/ASA-treated extracts. Only the infusion of the untreated placental extract induced a significant decreased in the incidence of fetal breathing. Fetal plasma prostaglandins increased significantly only with the infusion of the untreated placental extracts. These findings suggest that the inhibition of breathing observed with the placental extract is likely related to prostaglandins.

Failed individual and sequential instrumental vaginal delivery: contributing risk factors and maternal-neonatal complications.

BACKGROUND: To identify the risk factors for failed instrumental vaginal delivery, and to compare maternal and neonatal morbidity associated with failed individual and sequential instruments used. DESIGN: A retrospective case-control study. METHODS: From January 1995 to June 2001, there were 39 508 live births at >37 weeks' gestation of which 2628 (6.7%) instrumental vaginal deliveries were performed, 1723 (4.4%) were vacuum extractions and 905 (2.3%) were forceps. A total of 155/2628 (5.9%) patients who had failed instrumental delivery were matched with 204 patients who had successful instrumental delivery. The patients were divided into five groups. Group I (n = 129) had failed vacuum extraction, group II (n = 13) failed forceps, group III (n = 13) failed both (i.e. failed attempt at both instruments sequentially), group IV (n = 138) had successful vacuum extraction and group V (n = 66) successful forceps. RESULTS: The failure rate for vacuum extractions 129/1723 (7.5%) was significantly higher than that for forceps 13/905 (1.4%) [odds ratio (OR) = 5.6, 95% CI 3-10.3]. There were no significant differences in all maternal complications (25.5% vs. 26.6%) between vacuum (groups I and IV) and forceps (groups II and V) assisted deliveries. There were more maternal complications in group III (46.2%) than in groups I (35.7%), II (23.1%) and V (27.3%) that did not reach statistical significance but were significantly higher than in group IV (15.9%, OR = 4.5, 95% CI 1.2-16.9). There was a significantly higher rate of all fetal complications in group III [11/13 (84.6%)] than in groups I [69/129 (53.5%)], II [7/13 (53.8%)], IV [35/138 (25.4%)] and V [22/66 (33.3%)] (OR = 4.8, 95% CI 0.9-19.9). CONCLUSIONS: Applying the instrument at < or =0 fetal station, nulliparous women, history of previous cesarean section and fetal head other than occipitoanterior position were risk factors for failed instrumental delivery. Sequential use of instrumental delivery carries a significantly higher neonatal morbidity than when a single instrument is used.

Congenital rickets caused by maternal vitamin D deficiency.

The cases of four newborn infants with congenital rickets are reported. All infants were native Canadian: three were Cree and one was Inuit. One had a narrow chest and pulmonary hypoplasia, two had clinical and radiological signs of rickets with craniotabes, thickened wrists, and prominent costochondral junctions, and one had perinatal asphyxia and hydrops. All had hypocalcemia, hypophosphatemia and secondary hyperparathyroidism. Serum 25-hydroxyvitamin D levels were low in three of the infants. The four mothers had evidence of vitamin D deficiency. All infants recovered following treatment with 5000 IU oral vitamin D daily.