A neonate with a meningomyelocele complicated by Aeromonas caviae ventriculoperitoneal shunt infection.

We report on a newborn girl with a Aeromonas caviae shunt infection and meningitis after insertion of a ventriculoperitoneal shunt and surgical repair of a meningomyelocele in one procedure. This pathogen has never been reported, related to ventriculoperitoneal shunt infections. Beside the need for surgical revision of the shunt because of shunt obstruction and septa formation in the ventricles, the clinical outcome was good with intravenous cefotaxime therapy.

Restrictive dermopathy: a case report and a critical review of all hypotheses of its origin.

Restrictive dermopathy (RD) is a rare, fatal, autosomal recessive genodermatosis in which tautness of a translucent thin skin is the major clinical observation. This causes an intrauterine fetal akinesia deformation sequence (FADS) resulting in polyhydramnios, reduced fetal movements at around 31 weeks gestation, dysmorphic facies, arthrogryposis, and early neonatal death because of respiratory insufficiency. The characteristic histologic abnormalities of the skin are located in a thin dermis, consisting of compactly arranged collagen fibers, scant elastic fibers, and poorly developed skin appendages. The epidermal rete ridges are flattened and the dermal-hypodermal border is remarkably straight. The etiology of these changes remains unclear. We tested several existing hypotheses and could not confirm them. These included fibroblast dysfunction, abnormal keratin composition, desmosomal changes, and increased proinflammatory cytokines [tumor necrosis factor (TNF)-alpha and interleukin (IL)-6]. We conclude that RD is a relatively easy clinical and pathologic diagnosis, but that the pathogenesis of the disease is not clarified.

The role of inflammation in the development of chronic lung disease in neonates.

UNLABELLED: Chronic lung disease (CLD) has been associated with chorioamnionitis and upper respiratory tract colonisation with Ureaplasma urealyticum. The aim of this review is to describe the increasing evidence that inflammation plays a critical role in the early stages of CLD of the neonate. Ongoing lung damage in the premature infant may be caused by failure to downregulate and control this inflammatory response. Tumour necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6) and IL-8 are important pro-inflammatory cytokines of which IL-8 is an important chemotactic factor in the lung. Data suggest that preterm newborns with lung inflammation may be unable to activate the anti-inflammatory cytokine IL-10. Therefore, early post-natal anti-inflammatory therapy could help in preventing development of CLD. Prophylactic dexamethasone therapy cannot yet be recommended. There are a number of potential interactions between surfactant and cytokine effects on the preterm lung which have not been evaluated. Surfactant protein A may be an important modulator of the immune response to lung injury. The role of high-frequency ventilation in the prevention of CLD still remains unclear. CONCLUSION: Many aspects of the pathogenesis of the inflammatory response in the development of chronic lung disease remain to be elucidated. Further research to identify preterm infants at highest risk for the development of this multifactorial and complex disease is needed.

Microbiology and risk factors for catheter exit-site and -hub colonization in neonatal intensive care unit patients.

OBJECTIVE: To identify risk factors and describe the microbiology of catheter exit-site and hub colonization in neonates. DESIGN: During a period of 2 years, we prospectively investigated 14 risk factors for catheter exit-site and hub colonization in 862 central venous catheters in a cohort of 441 neonates. Cultures of the catheter exit-site and hub were obtained using semiquantitative techniques at time of catheter removal. SETTING: A neonatal intensive care unit at a university hospital. RESULTS: Catheter exit-site colonization was found in 7.2% and hub colonization in 5.3%. Coagulase-negative staphylococci were predominant at both sites. Pathogenic flora were found more frequently at the catheter hub (36% vs 14%; P<.05). Through logistic regression, factors associated with exit-site colonization were identified as umbilical insertion (odds ratio [OR], 8.1; 95% confidence interval [CI95], 2.35-27.6; P<.001), subclavian insertion (OR, 54.6; CI95, 12.2-244, P<.001), and colonization of the catheter hub (OR, 8.9; CI, 3.5-22.8; P<.001). Catheter-hub colonization was associated with total parenteral nutrition ([TPN] OR for each day of TPN, 1.056; CI95, 1.029-1.083; P<.001) and catheter exit-site colonization (OR, 6.11; CI95, 2.603-14.34; P<.001). No association was found between colonization at these sites and duration of catheterization and venue of insertion, physician's experience, postnatal age and patient's weight, ventilation, steroids or antibiotics, and catheter repositioning. CONCLUSION: These data support that colonization of the catheter exit-site is associated with the site of insertion and colonization of the catheter hub with the use of TPN. There is a very strong association between colonization at both catheter sites.

Risk factors for central vascular catheter-associated bloodstream infections among patients in a neonatal intensive care unit.

The aim of this study was to identify risk factors for catheter-associated bloodstream infection (CABSI) in neonates. We undertook a prospective investigation of the potential risk factors for CABSI (patient-related, treatment-related and catheter-related) in a neonatal intensive care unit (NICU) using univariate and multivariate techniques. We also investigated the relationship between catheter hub and catheter exit site colonization with CABSI.Thirty-five episodes of CABSI occurred in 862 central catheters over a period of 8028 catheter-days, with a cumulative incidence of 4.1/100 catheters and an incidence density of 4.4/1000 catheter days. Factors independently associated with CABSI were: catheter hub colonization (odds ratio [OR] = 44.1, 95% confidence interval [CI] = 14.5 to 134.4), exit site colonization (OR = 14.4, CI = 4.8 to 42.6), extremely low weight (< 1000 g) at time of catheter insertion (OR = 5.13, CI = 2.1 to 12.5), duration of parenteral nutrition (OR=1.04, CI=1.0 to 1.08) and catheter insertion after first week of life (OR = 2.7, CI = 1.1 to 6.7). In 15 (43%) out of the 35 CABSI episodes the catheter hub was colonized, in nine (26%) cases the catheter exit site was colonized and in three (9%) cases colonization was found at both sites. This prospective cohort study on CABSI in a NICU identified five risk factors of which two can be used for risk-stratified incidence density description (birthweight and time of catheter insertion). It also emphasized the importance of catheter exit site, hub colonization and exposure to parenteral nutrition in the pathogenesis of CABSI.

Catheter manipulations and the risk of catheter-associated bloodstream infection in neonatal intensive care unit patients.

A prospective cohort study was performed to evaluate the influence of catheter manipulations on catheter associated bloodstream infection (CABSI) in neonates. Neonates admitted between 1 November 1993 and 31 October 1994 at the neonatal intensive care unit of a university hospital were included in the study. Seventeen episodes of CABSI occurred in 357 central catheters over a period of 3470 catheter-days, with a cumulative incidence of 4.7/100 catheters and an incidence density of 4.9/1000 catheter-days. Patient and catheter-related risk factors independently associated with CABSI were: catheter hub colonization (odds ratio [OR] = 32.6, 95% confidence interval [95% CI] = 4.3-249), extremely low weight (

Additional hospital stay and charges due to hospital-acquired infections in a neonatal intensive care unit.

A comparative retrospective cohort study was performed to evaluate the influence of hospital-acquired infection (HAI) in neonates on additional charges and hospital stay. Neonates admitted between October 1993 and discharged alive before December 1995 at the neonatal intensive care unit of a university hospital were studied. Of 515 neonates, 69 (13%) had one or more HAI; 45 (20 with proven HAI, 25 with suspected HAI) were matched to 45 controls. After matching for gestational age, surgery, artificial ventilation and patent ductus arteriosus, central vascular catheter utilization was the only factor significantly associated with HAI. Charges were obtained from hospital discharge abstracts and the duration of hospitalization from patients' files. The mean additional length of hospital stay in neonates with HAI was 24 days (54 days vs. 30 days, P= 0.002) but did not differ significantly in patients with proven or suspected HAI (67 days vs. 51 days, P> 0.05). The mean extra charges for patients with a HAI were 11 750 EURO (9635 pounds). Accommodation accounted for 72%, fees for 22%, pharmaceuticals for 5% and ancillary items for 1% of these extra charges. The mean charges per day were similar for controls [443 EURO (363 pounds)] and HAI patients [453 EURO (372 pounds)]. Overall charges and charges per day were similar for neonates with proven and suspected HAI.

A prospective study on factors influencing aspergillus spore load in the air during renovation works in a neonatal intensive care unit.

The relationship between air contamination (cfu/m(3)) with fungal spores, especially Aspergillus spp., in three renovation areas of a neonatal intensive care unit (NICU) and colonization and infection rates in a high care area (HC) equipped with high efficiency particulate air (HEPA) filtration and a high pressure system, was evaluated. Data on the type and site of renovation works, outdoor meteorological conditions, patient crowding and nasopharyngeal colonization rate were collected. Factors not associated with Aspergillus spp. concentration were outdoor temperature, air pressure, wind speed, humidity, rainfall, patient density in the NICU, renovation works in the administrative area and in the isolation rooms. Multivariate analysis revealed that renovation works and air concentration of Aspergillus spp. spores in the medium care area (MC) resulted in a significant increase of the concentration in the HC of the NICU. The use of a mobile HEPA air filtration system (MedicCleanAir(R)Forte, Willebroek, Belgium) caused a significant decrease in the Aspergillus spp. concentration. There was no relationship between Aspergillus spp. air concentration and nasopharyngeal colonization in the neonates. Invasive aspergillosis did not occur during the renovation. This study highlights the importance of optimal physical barriers and air filtration to decrease airborne fungal spores in high-risk units during renovation works. The value of patient surveillance and environmental air sampling is questionable since no relationship was found between air contamination and colonization in patients.

Prediction of nosocomial sepsis in neonates by means of a computer-weighted bedside scoring system (NOSEP score)

OBJECTIVE: To develop an easy-to-use bedside scoring system, composed of clinical variables, hematologic variables, and risk factors of infection, to predict nosocomial sepsis in neonatal intensive care unit patients. SETTING: A neonatal intensive care unit in a university hospital, Antwerp, Belgium. PATIENTS: Over 2 yrs, we analyzed two groups of patients. First, we prospectively studied 104 episodes of presumed nosocomial sepsis in 80 neonates (derivation cohort), and then we retrospectively studied 50 episodes in 39 neonates (validation cohort). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We developed two versions of a scoring system to predict nosocomial sepsis in sick neonates. The first scoring system (NOSEP-1 score) was based on 15 clinical, 12 laboratory, and 17 historical variables potentially connected with infection; the second one (NOSEP-2 score) also included the culture results of central vascular catheters. Based on the odds ratios of all independent variables, an additive and weighted score was developed and validated in a cohort of 39 patients screened for nosocomial sepsis in the same center. The NOSEP-1 score consisted of three laboratory variables (C-reactive protein > or =14 mg/L, thrombocytopenia <150 x 10(9)/L, and neutrophil fraction >50%), one clinical factor (fever >38.2 degrees C [100.8 degrees F]), and one risk factor (parenteral nutrition for > or =14 days). The NOSEP-2 score consisted of the same variables plus catheter-hub and catheter insertion site colonization data. Receiver operating characteristic curve analysis demonstrated good predictor performance of the NOSEP-1 score (area under the curve [Az] = 0.82 +/- 0.04 [SEM]) and NOSEP-2 score (Az = 0.84 +/- 0.04, p < .05). We checked whether a complex computer-generated scoring system (CD-1 and CD-2 scores) based on the original numerical values of the items used in NOSEP-1 and NOSEP-2 would improve the prediction of nosocomial sepsis. The analysis showed the accuracy of bedside NOSEP-1 and NOSEP-2 scores to be comparable with the more cumbersome computer-generated CD-1 and CD-2 scores (receiver operating characteristic curve, Az: CD-1 score = 0.81 +/- 0.04, p = .69, and CD-2 score = 0.86 +/- 0.04, p = .96). Finally, in the validation cohort, we showed that the developed scoring system has a good prediction potential for nosocomial sepsis (Hosmer-Lemeshow goodness-of-fit test, chi2 [19] = 16.34, p > .75). CONCLUSIONS: The simple bedside scoring system NOSEP-1 composed of C-reactive protein, neutrophil fraction, thrombocytopenia, fever, and prolonged parenteral nutrition exposure provides a valuable tool for early identification of nosocomial sepsis. Its predictive power can be improved by adding central vascular catheter insertion site and hub colonization to the score.

Obstetricians' compliance with CDC guidelines on maternal screening and intrapartum prophylaxis for group B streptococcus.

How obstetricians' opinions regarding universal screening of pregnant woman for group B streptococcus and their attitude regarding chemoprophylaxis vary from the Centres for Disease Control (CDC) guidelines were studied, and the physician characteristics that predict divergent opinions were determined. Five hundred and eighty-two obstetricians in the Flanders region of Belgium were contacted by a postal survey. Ordinal logistic regression was used to assess obstetricians' characteristics that predict divergence. Only 44% agreed with routine prenatal screening for group B streptococcus of whom 72% would screen at 35 weeks. Intrapartum prophylaxis would be done on the basis of risk factors alone in 38%. Multivariate analysis revealed significant provincial differences (best in Antwerp, worst in West-Flanders) and increasing age was associated with decreasing compliance. It is concluded that a minority of the obstetricians believes in routine prenatal screening and one-third would give prophylaxis on the basis of risk factors alone. Obstetrician's age and province of practice predict divergent opinions.

A retrospective epidemiological study of bacterial meningitis in an urban area in Belgium.

UNLABELLED: In order to obtain epidemiological data on the incidence of bacterial meningitis (BM) before the systematic introduction of vaccination against Haemophilus influenzae type b, a retrospective study of 124 children with proven BM was performed in an urban area in Belgium. N. meningitidis was the most prevalent cause, followed by H. influenzae and S. pneumoniae. Over a period of 6 years the incidence of BM increased ten fold, mainly due to an increase in N. meningitidis. The median age of the children with BM was 17 months and 35% of those with H. influenzae were younger than 1 year. Significant risk factors for BM as a whole were: age under 1 year, male gender, non-Caucasian descent and winter time. These findings may have implications for future vaccination policy in Belgium. CONCLUSION: Future vaccination schemes in Belgium should take into account than N. meningitis was the prevalent cause of bacterial meningitis and that certain factors increase the risk for developing bacterial meningitis.

Congenital streptococcal toxic shock syndrome with absence of antibodies against streptococcal pyrogenic exotoxins.

Congenital infection with group A beta-hemolytic streptococcus was complicated by toxic shock syndrome in a neonate. We hypothesize that the severity of the clinical syndrome was related to the streptococcal pyrogenic exotoxin in the absence of corresponding antibodies. The outcome may have been favorably influenced by the antibodies to streptococcal pyrogenic exotoxin present in the immunoglobulins given as treatment.

Clinical experience with ceftriaxone treatment in the neonate.

The safety of ceftriaxone has been evaluated in 80 neonates who were treated empirically for suspected infection with either ceftriaxone and ampicillin (group A, age 0-72 h) or ceftriaxone and vancomycin (group B, age greater than 72 h). Within 48 h after birth 2 group A patients died from sepsis (Haemophilus influenzae, Streptococcus pneumoniae, 1 case each); 1 group B patient died from sepsis (Pseudomonas aeruginosa). All bacterial isolates from group A patients were susceptible to ceftriaxone, but in 4 of the 8 group B patients with positive cultures a change in antibiotic therapy was required. Eosinophilia, thrombocytosis and an increase in serum alkaline phosphatases were observed in a limited number of patients during and after discontinuation of treatment. Direct hyperbilirubinemia ( > 2 mg/dl) occurred in 2 cases during treatment. Gallbladder sludge was sonographically diagnosed in 6 patients, but disappeared within 2 weeks after detection. One neonate had exanthema. Nurses rated ease of administration as very good. Ceftriaxone appears to be an interesting alternative in the empiric antibiotic treatment in the early neonatal period.

Imidazoline intoxication in children.

A 15-month-old girl with rhinopharyngitis was treated with a nasal solution containing the imidazoline derivative naphazoline. She rapidly developed profound CNS depression with stupor, hypothermia, hypoventilation and bradycardia. All symptoms disappeared within 24 h. The symptomatology of 18 other paediatric cases of naphthylimidazoline exposure reported to the Belgian National Poison Centre, is also discussed. Imidazoline intoxication due to overdose or accidental ingestion but also after normal therapeutic usage is frequent in children. It can cause severe CNS depression, especially in very young children. For these reasons vasoconstrictor imidazoline containing solutions should be prescribed with caution and kept out of reach of children.