One size does not fit all: why universal decolonization strategies to prevent methicillin-resistant Staphylococcus aureus colonization and infection in adult intensive care units may be inappropriate for neonatal intensive care units.

The REDUCE MRSA Trial (Randomized Evaluation of Decolonization vs Universal Clearance to Eliminate Methicillin-Resistant Staphylococcus aureus), a large multicenter, randomized controlled trial in adult intensive care units (ICUs), found universal decolonization to be more effective than surveillance and isolation procedures with or without targeted decolonization for reducing rates of MRSA-positive clinical cultures. The Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention subsequently published protocols for implementing universal decolonization in ICUs based on the trial's methods. Caution should be exercised before widely adopting these procedures in neonatal intensive care units (NICUs), particularly strategies that involve bathing with chlorhexidine and mupirocin application due to the potential for adverse events in their unique patient population, especially preterm infants. Large multicenter trials in the NICUs are needed to evaluate the efficacy, short- and long-term safety, and cost effectiveness of these strategies prior to their widespread implementation.

Early-onset neonatal sepsis in the era of group B streptococcal prevention.

OBJECTIVE: To determine whether intrapartum antibiotic prophylaxis for neonatal group B streptococcal (GBS) disease has resulted in an increased rate of non-GBS or antibiotic-resistant early-onset invasive neonatal disease. METHODS: Maternal and infant chart review of all infants with bacteria other than GBS isolated from blood or spinal fluid in 1996 through 1999 in 19 hospitals (representing 81% of in-state births to state residents) throughout Connecticut. Suspected cases were identified through clinical microbiology laboratory records or through International Classification of Diseases, Ninth Revision codes when microbiology records were incomplete. RESULTS: Ninety-four cases of non-GBS early-onset sepsis or meningitis were detected between 1996 and 1999. The rate of GBS-related early-onset infection (days 0-6 of life) dropped from 0.61/1000 to 0.23/1000 births, but the annual rate of non-GBS sepsis remained steady, ranging from 0.65 to 0.68/1000 during the surveillance period. There was an increase in the proportion of Escherichia coli infections that were ampicillin resistant between 1996 and 1998, but the proportion decreased. in 1999 CONCLUSION: There was no increase in the incidence of non-GBS early-onset neonatal infections between 1996 and 1999. Fluctuations in the annual incidence of E coli infections, including ampicillin-resistant infections, suggest the need for continuation of surveillance in Connecticut and expansion to monitor larger populations.

Molecular typing demonstrating transmission of gram-negative rods in a neonatal intensive care unit in the absence of a recognized epidemic.

Molecular typing techniques have been used in outbreak investigations. In this study, molecular typing techniques were used to track the spread of gram-negative rods (GNRs) in a neonatal intensive care unit (NICU) in the absence of an outbreak. Stool or rectal swab cultures for GNRs were obtained from all infants on admission, weekly, and on discharge. GNRs were tested for gentamicin susceptibility and were typed by contour-clamped homogeneous electric field electrophoresis. Transmission of identical strains of GNRs among infants was noted. Shared strains were more gentamicin resistant compared with unique strains (53% vs. 10%; P=.0001). Infants first colonized when they were >1 week of age had more total days of antibiotic treatment and had a higher rate of acquiring a shared and gentamicin-resistant strain, compared with infants colonized earlier. Antibiotic use increases colonization of infants in the NICU with resistant and shared strains of GNRs.

A World Wide Web selected bibliography for pediatric infectious diseases.

A pediatric infectious diseases bibliography of selected medical reference citations has been developed and placed on the World Wide Web (WWW) at http://www.pedid.uthscsa.edu. A regularly updated bibliography of >2,500 selected literature citations representing general reviews and key articles has been organized under a standard outline for individual infectious diseases and related topics that cover the breadth of pediatric infectious diseases. Citations are categorized by infectious disease or clinical syndrome, and access can be achieved by the disease or by syndrome or the name of the pathogen. Abstracts, and in some cases the complete text of articles, may be viewed by use of hypertext links. The bibliography provides medical students, residents, fellows, and clinicians with a constantly available resource of current literature citations in pediatric infectious diseases. The WWW is an emerging educational and clinical resource for the practice of clinical infectious diseases.

Antibiotic resistance.

The problem of resistance of microorganisms to antibiotics is not new, but in the past few years the development of resistance in common pathogens has heightened awareness and coverage in the lay press, as well as influential general scientific and medical journals. This has alerted public attention to the problem.

Neonatal nosocomial infections.

Nosocomial acquisition of infection is now the most common mode of transmission of infection in neonatal intensive care units (NICUs). Surveillance studies have shown rates of infection in the NICU of 15% to 20%, which are as high as those in adult medical or surgical ICUs and higher than those in most pediatric ICUs. Studies of NICU nosocomial infections have pinpointed the use of indwelling vascular catheters, high-calorie hyperalimentation infusions, assisted ventilation, and prior use of antibiotics as significant risk factors for infection. Strategies to reduce nosocomial infections with the use of prophylactic antibiotics, immunoglobulins, and physical barriers have been unsuccessful. New methods of reducing risk factors and enhancing the neonate's resistance to infection are badly needed.

Management of rabies exposure in pediatric practice.

The incidence of human rabies in the United States has fallen dramatically over the past 4 decades. This is directly related to the universal immunization of domestic cats and dogs. Recently, a number of cases of human rabies have been associated with the appearance of a previously rare strain of the virus in the silver-haired bat. There have been other recent changes in the epizoology of rabies with the expansion of raccoon rabies from a small pocket around northern Virginia to most of the northeastern United States. Postexposure prophylaxis using rabies immune globulin and rabies vaccine is effective in preventing rabies following a bite by a rabid animal when given according to current recommendations. There has been considerable debate, however, surrounding the cost of prophylaxis and the possibility of reducing the recommended number of doses of rabies immune globulin.

Bloodstream infections in neonatal intensive care unit patients: results of a multicenter study.

For identification of risk factors for bloodstream infection (BSI) among neonatal intensive care unit patients, prospective 6-month studies in three neonatal intensive care units were conducted. BSI was diagnosed in 42 of 376 (11.2%) enrolled infants. Pathogens included coagulase-negative staphylococci, Candida sp., Group B streptococci and Gram-negative species. Patients with BSIs were more likely to die during their neonatal intensive care unit stay than were patients who did not acquire BSIs (6 of 42 vs. 11 of 334, P = 0.007). BSI rate was highest in infants with birth weight < 1500 g (relative risk (RR) = 6.8, P < 0.001), those treated with H-2 blockers (RR = 4.2, P < 0.001) or theophylline (RR = 2.8, P < 0.001) and those with admission diagnoses referable to the respiratory tract (RR = 3.7, P < 0.001). Infants who developed BSI were more severely ill on admission than other infants (median physiologic stability index 13 vs. 10 (P < 0.001) and were of lower gestational age (28 vs. 35 weeks, P < 0.001). In logistic regression analysis, risk of BSI was independently associated only with very low birth weight, respiratory admission diagnoses and receipt of H-2 blockers. Risk of isolation of a pathogen from blood culture was independently associated with Broviac, umbilical vein or peripheral venous catheterization > 10, 7 or 3 days, respectively, at one insertion site. Rate of isolation of a pathogen was higher (9 of 59 (15%)) within 48 hours of a measurable serum interleukin 6 concentration than an interleukin 6 level of 0 pg/ml (10 of 159 (6%), P = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of antibiotic use in a neonatal intensive care unit.

OBJECTIVE: To determine the incidence and pattern of antibiotic use in a neonatal intensive care unit (NICU). DESIGN: Prospective study of a one-month NICU cohort. Investigators visited each subject, checking nursing notes, antibiotic flow sheets, and laboratory data at each daily visit. SETTING: The NICU at Yale-New Haven Hospital, New Haven, Connecticut; a regional care, level 3 unit in a tertiary care medical center. PATIENTS: All infants admitted to the NICU for one month (n = 63) who resided in the unit for > or = 24 hours. RESULTS: 75% of the infants had antibiotic treatment begun in the first 48 hours of life. The highest rate of antibiotic treatment starts was in premature infants with birthweight less than 1,500 g, 92% of whom received antibiotics in the first 48 hours. In the subsequent days of life the incidence of starting antibiotic treatment was low and sporadic and the prevalence of antibiotic treatment by day of life showed a sharp decline between the third and fourth days of life. Five cross-sectional studies in the nursery showed point-prevalence rates of antibiotic use to be 27% to 43% of the whole NICU population, highest in the intensive care sector of the unit and in those < 72 hours of age. CONCLUSIONS: The high incidence of antibiotic starts in this NICU was largely the result of almost universal treatment of premature infants beginning on the first day of life. The risk of infection in these infants is quite low; more information is needed concerning how to distinguish infants who do not require treatment. This study provides comparison data for NICUs compiling data on incidence and prevalence of antibiotic use and developing programs to limit antibiotic use.

Infective endocarditis in children.

IE in children is associated primarily with underlying congenital structural heart lesions, predominantly septal defects or complex lesions involving septal defects. During the past 20 years IE associated with rheumatic heart disease has declined to a negligible number. Recently nosocomial catheter-associated bacteremia has been associated with the development of IE, especially in infants. Streptococci are most frequently associated with IE involving natural valves. Although streptococci have also been implicated in cases of IE associated with previous surgery or catheter-related infection, staphylococci, Gram-negative rod species and multiple infecting species are also encountered in this setting. Because infection can often be managed medically, removal of grafts or prosthetic valves is not necessary unless clinical or microbiologic failure occurs. Penicillin with or without an aminoglycoside is the regimen for most community-acquired streptococcal IE. A penicillinase-resistant beta-lactam generally is substituted for penicillin in IE caused by an unknown agent and is used in cases of staphylococcal IE. For IE caused by resistant staphylococci, vancomycin is the alternative agent. Currently there is limited information on the efficacy of alternative agents for treating IE caused by enterococci or staphylococci with multiple antibiotic resistance.

A ten-year review of neonatal sepsis and comparison with the previous fifty-year experience.

Records have been kept prospectively in our institution since 1928 of all positive blood cultures taken from neonates. Using a modification of objective Centers for Disease Control criteria to define sepsis, we reviewed the records of all neonates with positive blood cultures for the years 1979 to 1988 inclusive and found 270 cases of sepsis. The sepsis rate for infants less than or equal to 30 days of age was 2.7 cases/1000 live births, with a mortality rate from sepsis of 15.9%. There was an increase in sepsis due to commensal species (CS) over the period (P less than 0.007). The number of infants in the nursery who developed sepsis when more than 30 days of age also increased (P less than 0.002), as did the rate of sepsis from CS in this group (P less than 0.001). Isolation of CS from the blood with fulfillment of the modified Centers for Disease Control criteria was associated with a 13.7% mortality rate, whereas isolation of CS without fulfillment was associated with a 4% rate (P less than 0.01).