The role of renal biomarkers to predict the need of surgery in congenital urinary tract obstruction in infants.

INTRODUCTION: The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage. OBJECTIVE: The aim of the study was to investigate a selection of promising biomarkers of renal injury with the intention of evaluating and comparing their profile with clinically based decisions for surgical intervention of infants with congenital obstructive uropathies. STUDY DESIGN: The first-year profile of renal biomarkers, serum creatinine (sCr), serum and urine cystatin C (CyC), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-ß1), retinol-binding protein (RBP), and microalbuminuria (µALB), was analyzed in a cohort of 37 infants with congenital UTO, divided into three subgroups, 14 cases with grade III unilateral hydro(uretero)nephrosis, 13 cases with grade III bilateral hydro(uretero)nephrosis, and 10 cases with low urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. Serum and urine samples were stored at -70 °C and thereafter analyzed by quantitative enzymatic immunoassay. RESULTS: Compared with the control group (Figure), all renal biomarker values were significantly increased in patients (P ≤ 0.02). In the unilateral hydronephrosis and LUTO group, RBP (P ≤ 0.043), NGAL (P ≤ 0.043), KIM-1 (P ≤ 0.03), and TGF-ß1 (P ≤ 0.034) values dropped significantly after surgery. Neutrophil gelatinase-associated lipocalin alone and in combination with urine and serum CyC demonstrated the best performance in determining the need for surgery (area under the curve, 0.801 and 0.881, respectively). Biomarker profile analysis was suggestive of surgical intervention in 55.4% (7/13) of non-operated cases, and most of the biomarker values were above the cutoff levels within at least 3 months before the clinically based surgical decision in 58% (14/24) of all operated patients. DISCUSSION: To the best of the authors' knowledge, this is the first study to present the clinical use of selected group of serum and urinary biomarkers in the setting of UTO to distinguish between patients who would benefit from surgery intervention. The most promising results were obtained using NGAL, RBP, TGF-ß1, and KIM-1, especially in the unilateral hydro(uretero)nephrosis and LUTO subgroups when compared with the control group. CONCLUSIONS: Urine biomarkers, alone and in combination, demonstrated high potential as a non-invasive diagnostic tool for identifying infants who may benefit from earlier surgical intervention.

Oral colonization: a possible source for candidemia in low-weight neonates.

OBJECTIVE: To check the oral colonization in neonates at high-risk and to associate these cases with candidemia. SUBJECTS AND METHODS: This study was conducted in the NICU. For six months, 125 high-risk neonates were investigated for oral colonization and septicemia by yeasts. From this total, 19 neonates had yeasts on the oral mucosae and 12 neonates developed fungemia. All of the 12 neonates with fungemia were included in the amount of 19 who have presented oral colonization by yeasts. RESULTS: There was a species concordance between the yeasts of the oral mucosae and the blood in 6 neonates (50%) among the 12 neonates with oral colonization and septicemia at the same time. The yeasts isolated in these 6 cases regarding the species concordance were Candida albicans (5 cases, 83.4%) and Candida parapsilosis (1 case, 16.6%). All of the cases involving an association were confirmed by PFGE. All of the strains of yeasts involved in oral colonization and also blood presented the same karyotype. A total of 66.6% of the patients with strains in agreement progressed to death. CONCLUSION: The results indicate the relevance of monitoring the oral microbiota, as a possible source of fungal infection, and assisting to develop appropriate therapeutic strategy.

Investigation of an outbreak of Enterobacter cloacae in a neonatal unit and review of the literature.

Enterobacter cloacae has emerged as an important pathogen in neonatal units, with several outbreaks of infection being reported. The aim of this study was to investigate an outbreak of sepsis due to E. cloacae in a neonatal unit and to review the literature. A retrospective cohort study was conducted in which cases were compared with all newborns hospitalised for more than 48h in the neonatal intensive care unit (NICU). Cohorting of infected patients and work reorganisation were implemented. Pulsed-field gel electrophoresis was performed. The retrospective cohort included the six cases and 13 control patients that had been in the NICU during April 2006. Univariate analysis showed that the use of dobutamine was significantly associated with infection (P=0.036) and that enteral feeding was a protective factor (P=0.02). Multivariate analysis did not find any independent risk factor. Bed occupancy rate in March 2006 was 109.6%, indicating overcrowding. PFGE identified indistinguishable patterns among isolates from all six newborns. PubMed and OVID was search from 1 January 1983 to 15 January 2008 for papers including the terms 'E. cloacae', 'outbreaks', 'clusters' in combination with 'neonate', 'newborn', and 'infant'. We found 26 reports of outbreaks due to E. cloacae in neonate patients: sixteen (52%) were bloodstream infection outbreaks, of which two (12.5%) were related to multiple-dose medications. The source for our outbreak was not identified. Reinforcement of hygiene practices, restrictions on new admissions and the establishment of single-dose medications helped to control the outbreak.

Necrotizing fasciitis in a newborn infant: a case report.

We report the case of a one-day-old newborn infant, female, birth weight 1900 g, gestational age 36 weeks presenting with necrotizing fasciitis caused by E. coli and Morganella morganii. The newborn was allowed to fall into the toilet bowl during a domestic delivery. The initial lesion was observed at 24 hours of life on the left leg at the site of the venipuncture for the administration of hypertonic glucose solution. Despite early treatment, a rapid progression occurred resulting in a fatal outcome. We call attention to the risk presented by this serious complication in newborns with a contaminated delivery, and highlight the site of the lesion and causal agents.

Vancomycin monitoring in term newborns: comparison of peak and trough serum concentrations determined by high performance liquid chromatography and fluorescence polarization immunoassay.

INTRODUCTION: Peak and trough serum concentrations of vancomycin were determined in term newborn infants with confirmed or suspected Staphylococcus sp sepsis by high performance liquid chromatography and flourescence polarization immunoassay. OBJECTIVE: To statistically compare the results of the high performance liquid chromatography and flourescence polarization immunoassay techniques for measuring serum vancomycin concentrations. METHODS: Eighteen peak and 20 trough serum samples were assayed for vancomycin concentrations using high performance liquid chromatography and flourescence polarization immunoassay from October 1995 to October 1997. RESULTS: The linear correlation coefficients for high performance liquid chromatography and flourescence polarization immunoassay were 0.27 (peak, P = 0.110) and 0.26 (trough, P = 0.1045) respectively, which were not statistically significant. CONCLUSION: There was wide variation in serum vancomycin concentrations determined by high performance liquid chromatography as compared with those determined by flourescence polarization immunoassay. There was no recognizable pattern in the variability; in an apparently random fashion, the high performance liquid chromatography measurement was sometimes substantially higher than the flourescence polarization immunoassay measurement, and at other times it was substantially lower.

Brain abscess by citrobacter diversus in infancy: case report.

Citrobacter diversus is closely related to brain abscess in newborn infants. We describe a case of brain abscess by this bacteria in a newborn infant and his clinical and cranial computed tomographic evaluation until the fourth month of life and discuss therapeutic management of this patient.

Endocardite bacteriana como complicaçäo de sepse neonatal: relato de caso / Bacterial endocarditis as a complication of neonatal sepsis: a case report

Os autores relatam um paciente com 11 dias de vida, internado em Unidade de Terapia Intensiva Neonatal devido a múltiplas malformações congênitas, apresentando sepse e endocardite bacteriana. Entre os fatores de risco para endocardite foram destacados o cateterismo venoso central, hemocultura com crescimento de Staphylococcus aureus e ventilação mecânica. O diagnóstico foi realizado no 61§ dia de internação devido a presença de febre persistente e aparecimento de sopro cardíaco sistólico. O ecocardiograma mostrou trombo em átrio direito, medindo 1,9 x 0,7mm sendo realizada antibioticoterapia e ressecção cirúrgica, com melhora clínica. No 125§ dia de internação ocorreu óbito devido à sepse e abscesso cerebral. Na necrópsia não foram observados malformações cardíacas. Os autores concluem ser de grande importância o conhecimento das complicações potenciais das técnicas invasivas utilizadas em recém-nascidos criticamente doentes. A suspeita clínica de endocardite deve ser realizada em todos os neonatos com sepse, internados em Unidade de Terapia Intensiva Neonatal por tempo prolongado.

[Bacterial endocarditis as a complication of neonatal sepsis: case report]. / Endocardite bacteriana como complicação de sepse neonatal--relato de caso.

The authors reported on a 11 day-old child, admitted in Neonatal Intensive Care Unit for multiple congenital malformations, who had sepsis and bacterial endocarditis. Among the risk factors for endocarditis were outstanding: the central venous catheterism, hemoculture with growth of Staphylococcus aureus and mechanical ventilation. The diagnosis was made in the 61st day after admission owing to the presence of persistent fever and appearance of systolic murmur. The echocardiogram revealed a thrombus in the right atrium measuring 1.9 x 0.7 mm. Antibiotic therapy and surgical resection being performed, with clinical improvement. On the 125st day after admission the patient died owing sepsis and cerebral abscess. At necropsy, heart malformations were not observed. The authors concluded to be very important the knowledge of the potential risks of invasive procedures currently used to care for critically ill newborns. The clinical suspicion of endocarditis should be considered in all neonates with sepsis and receiving intensive care for long time.

Central diabetes insipidus as a complication of neonatal pathology: report of three cases.

Three patients, 11, 17 and 41 days old with various degrees of central nervous system (CNS) lesions developed central diabetes insipidus as a complication of hypothalamic damage. Two of the children had congenital CNS malformations including meningomyelocele, hydrocephalus, and prosencephaly, while the third child presented Streptococcus agalactiae meningitis, complicated with CNS hemorrhage and hypertensive dilatation of the lateral ventricles. All of them fulfilled the criteria for central diabetes insipidus, reaching high levels of serum sodium and osmolality, along with hypotonic urine. The responses to intranasal arginine-vasopressin were prompt, normalizing the serum levels of sodium and increasing urinary osmolality, allowing a better metabolic balance, avoiding continuing damage to the already compromised CNS. The neonatologist must be aware of the possibility of this kind of complication even in a normal child with CNS infection. Imaging studies showing hemorrhage in the region of the posterior hypothalamus must be a sign that this type of complication is able to occur.

[Neonatal Streptococcus pyogenes meningitis and sagittal sinus thrombosis: case report]. / Meningite neonatal por Streptococcus pyogenes e trombose de seio sagital. Relato de caso.

We report a case of Streptococcus pyogenes meningitis in a 18 days year-old-girl with clinical course complicated by sagittal sinus thrombosis. Some aspects of the pathogenesis, treatment and follow-up of the disease are discussed. The world increase of serious streptococcal infections in the last 10 years, probably will become neonatal Streptococcus pyogenes meningitis more frequent in the future and it is important to be alert for the precocious diagnosis and the possible complications of that potentially lethal infection.

[Neonatal bacterial meningitis: prospective study of the long-term outcome of 55 children]. / Meningite bacteriana neonatal: estudo prospectivo da evolução a longo prazo de 55 crianças.

Fifty-five infants who presented bacterial neonatal meningitis were prospectively studied to analyze the frequency and the type of sequelae. All the infants were full term newborns. There were 38 boys and 17 girls; the age of disease onset varied from 3 to 28 days. The causative organism was represented mainly by enterobacteriae. The median time of follow-up was 5 years. The frequency of neurologic sequelae was 63.7%, represented mainly by neuropsychomotor development delay (58.2%), hydrocephaly (45.5%) and convulsions (34.5%). Severe motor abnormalities ocurred in 23.6% of children (quadriplegia, diplegia, hemiparesia and ataxia). Convulsions in the acute phase of the disease and the positive cerebrospinal fluid culture were highly associated to sequelae. The school performance, obtained in 25 children, showed presence of disabilities in 48% of cases, which were significantly associated to mental retardation.

[Bacterial meningitis in the neonatal period. Clinical evaluation and complications in 109 cases]. / Meningite bacteriana no período neonatal. Evolução clínica e complicações em 109 casos.

Bacterial meningitis has special clinical features in the newborn infant. Major complications and sequelae result from the infectious involvement of the CNS in the majority of these children. We studied 109 newborn infants with bacterial meningitis accompanied from January 1977 to April 1987. The mortality rate was 34.8%. Perinatal risk factors were not found. The majority (80.5%) were term newborn infants. The main signs at admission were convulsion (53.2%), bulging fontanel (37.6%) and apnea (20.2%), and the main symptoms were neurosensorial depression (64.2%), nursing refuse (64.2%), fever (50.5%) and irritability (35.8%). Complications during hospitalization were ventriculitis (34.9%), inappropriate antidiuretic hormone secretion syndrome (27.5%), subdural collection (8.3%), brain abscess (4.6%) and brain infarction (2.8%). Inappropriate antidiuretic hormone secretion syndrome and ventriculitis were closely associated with high mortality. Seventy one children survived: 44 (62%) had gross abnormalities at the neurologic examination, and 29 (40.8%) developed hydrocephalus. Neurological follow-up of these children is important. Prognostic can change along the course of long time follow-up.

Hipernatremia no periodo neonatal - analise de 18 casos. / Hypernatremia in the neonatal period - analysis of 18 cases

Os autores realizaram analise retrospectiva critica dos prontuarios de dezoito recem-nascidos com hipernatremia, relacionada a gastrenterite aguda em 15 casos e a bronquiolite, prematuridade e exsanguineo transfusao respectivamente nos outros tres Tecem comentarios sobre a patogenia e a fisiopatologia do estado hipernatremico e suas repercussoes sobre o sistema cardiocirculatorio e o sistema central.Enfatizam a alta frequencia das manifestacoes neurologicas e suas consequencias

Incontinencia pigmentar: relato de um caso. / Incontinentia pigmenti: a case report

Os autores apresentam um caso de incontinencia pigmentar, diagnosticado no periodo neonatal. Desde o nascimento a paciente apresentava lesoes cutaneas eritemato-vesicobolhosas em tronco, extremidades e couro cabeludo. Com quatro dias de vida teve convulsao. No hemograma observou-se eosinofilia. A biopsia de pele mostrou eosinofilos em toda a epiderme. Salientam-se os aspectos clinicos e laboratoriais da doenca, e a importancia do seguimento periodico dos pacientes, devido as alteracoes que podem surgir em outros orgaos

Salmonelose no periodo neonatal: analise de 55 casos. / Salmonellosis in the neonatal period: analysis of 55 cases

Os autores analisam a incidencia, a procedencia, o quadro clinico, os aspectos bacteriologicos, a terapeutica e as sequelas decorrentes da infeccao por Salmonella em 55 recem-nascidos. A contaminacao hospitalar e destacada assim como a importancia do aleitamento materno, o elevado custo operacional de suporte da doenca e a condicao de portador do microorganismo