Intravenous sildenafil i.v. as rescue treatment for refractory pulmonary hypertension in extremely preterm infants.

BACKGROUND: Intravenous sildenafil treatment has recently shown promising results and good tolerability in the treatment of refractory pulmonary hypertension (PH) in term and near-term neonates, while comparable data in preterm infants are still lacking. However, for critically ill preterm infants suffering from PH refractory to conventional treatment, sildenafil may represent a last treatment resort. PATIENTS AND METHODS: We reviewed the records of 6 critically ill extremely preterm infants who had suffered from PH refractory to conventional treatment and had obtained intravenous sildenafil after careful consideration as ultima ratio treatment. AIM: To describe the responses to sildenafil in terms of hemodynamic and respiratory changes during treatment and outcome. RESULTS: 4/6 patients showed resolution of severe PH with full reversal of ductal shunt direction into pure left-to-right shunt within 82 ± 35 h after sildenafil start. Remarkably, 2/6 patients developed pulmonary hemorrhage at a time point when significant improvement of PH had already taken place, both of them survived. Overall 4/6 patients died, two deaths were related to treatment-refractory PH. CONCLUSION: Intravenous sildenafil treatment seems effective in improving severe PH and hemodynamic instability in extremely preterm infants with refractory PH. Pulmonary hemorrhage may represent a distinct adverse effect of sildenafil treatment in these patients, presumably due to sudden reversal of ductal shunt. Accordingly, sildenafil should be restricted to most severe and refractory cases in this population.

Linezolid for treatment of catheter-related cerebrospinal fluid infections in preterm infants.

Ventriculostomy-related cerebrospinal fluid (CSF) infection remains a major problem in neonatal intensive care. The spectrum of pathogens causing these infections is dominated by coagulase-negative staphylococci, and vancomycin is the antibiotic of choice for treatment. However, vancomycin is known to have only poor penetration into the CSF when applied intravenously and is therefore being applied intraventricularly. The oxazolidinone linezolid has antibacterial activity against most drug-resistant Gram-positive bacteria and has been shown to have excellent penetration into the CSF in adults. Here, its successful use in five neonates with infected ventriculostomies is described.

The influence of subinhibitory concentrations of conventional and experimental antifungal drugs on the expression of the iC3b binding protein in Candida albicans strains during filamentation.

The influence of six antifungal agents on the expression of the fungal iC3b binding protein was studied in germ-tubes and the mycelial form of several Candida albicans strains. All antifungal agents inhibited not only the yeast-mycelial transformation, but also the formation of rosettes consisting of complement-coated sheep erythrocytes (EAiC3b) bound to the mycelial form of C. albicans. Immunofluorescence as well as ELISA, employing the monoclonal antibody OKM-1 which recognizes the alpha chain of human CR3 and which cross-reacts with the fungal iC3b binding protein, revealed that subinhibitory concentrations of 0.1 mg l(-1) (which did not affect the growth of either germ-tubes or the mycelial form of C. albicans) inhibited the expression of the iC3b binding protein, while lower concentrations (0.01 mg l(-1)) allowed a comparable and sometimes even slightly higher expression of this protein, in comparison with the untreated control. However, treatment with antifungal agents apparently did not lead to a major cleavage of the protein. The dependence of the amount of the iC3b binding protein expressed on the concentration of added antifungal drugs and on the morphological forms of individual C. albicans isolates suggests a drug dependent influence on the expression of this protein and a possible association with the changing virulence of C. albicans strains during antifungal therapy.

Temperature-dependent surface expression of the beta-2-integrin analogue of Candida albicans and its role in adhesion to the human endothelium.

Candida albicans has become one of the most important pathogens in intensive care units. Adherence of C. albicans to the vascular endothelium is believed to represent a critical step in the pathogenesis of disseminated candidiasis and may involve molecules analogous to human beta 2-integrins such as the complement receptor 3 (CR3) analogue of C. albicans (C.a.-CR3). Its expression was detected by a sensitive rosetting assay when Candida was present in its hyphal form but not in its yeast form, the latter being generally considered to be less pathogenic. However, the presence of hyphae alone was not sufficient: C.a.-CR3 expression was found to be temperature-dependent for 4 (out of 10) clinical isolates. Two rosetted better after growth at 30 degrees C, the other 2 after growth at 37 degrees C. This temperature dependence was most pronounced for 1 laboratory strain: C.a.-CR3 expression was best at 30 degrees C and markedly decreased with increasing temperatures. At 37 degrees C no rosettes were detected at all. Modifications of the culture conditions (e.g. agitation, pH) exerted a marked influence on the morphology of this strain but always allowed rosette formation once hyphae were formed at 30 degrees C. However, none of these modifications was able to induce rosettes at 37 degrees C. Adhesion of C. albicans isolates to an endothelial cell line was also temperature-dependent but not strongly correlated with C.a.-CR3 expression. Most strains exhibited a better adherence when grown at 30 degrees C. This finding may be of importance for exogenous infections, with Candida spp. invading the body from the outside, where the temperature is usually lower than the physiological body temperature.