[Procalcitonin for the diagnosis of neonatal sepsis of vertical transmission]. / Procalcitonina para el diagnóstico de sepsis neonatal de transmisión vertical.

OBJECTIVE: To evaluate procalcitonin (PCT) as a diagnostic marker of neonatal sepsis of vertical transmission and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: A prospective study was conducted in 136 blood samples from 69 newborn infants admitted to a neonatal department. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured. The PCT reference range of controls from 0 to 72 hours of life was constructed, and the diagnostic efficiency of the tests was calculated, with their 95 % confidence intervals (95 % CI). RESULTS: This study included 35 controls, 24 neonates with noninfectious disorders, and 10 neonates with sepsis (5 with culture-proven sepsis). PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.696 (p = 0.009), 0.735 (p = 0.002), and 0.703 (p = 0.006), respectively, with no statistically significant differences. The accuracy of PCT, CRP, and leukocyte count improved after 24 hours of life with areas under the ROC curve of 0.813 (p = 0.007), 0.826 (p = 0.005), and 0.841 (p = 0.003), respectively. Overall, PCT detected vertically transmitted sepsis with a sensitivity of 68.4 % (95 % CI: 46.0 %-84.6 %), specificity of 82.4 % (95 % CI: 72.2 %-89.4 %), positive likelihood ratio of 3.89 (95 % CI: 2.18 %-6.96 %), and negative likelihood ratio of 0.38 (95 % CI: 0.19 %-0.76 %), similar to those of CRP. CONCLUSIONS: PCT may be a useful marker for the diagnosis of vertically transmitted sepsis. Studies with larger sample sizes are required to establish the accuracy of PCT.

[Procalcitonin for the diagnosis of nosocomial neonatal sepsis]. / Procalcitonina para el diagnóstico de sepsis neonatal de origen nosocomial.

BACKGROUND: Nosocomial sepsis is a major problem in neonatal units. Because the clinical signs are nonspecific, highly reliable diagnostic markers are required to guide diagnosis. The aim of this study was to evaluate the utility of procalcitonin (PCT) as a diagnostic marker for nosocomial neonatal sepsis, and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: Twenty neonates with nosocomial sepsis and 20 controls aged 4-30 days were included in a prospective study performed in a neonatal intensive care unit. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured at onset of signs of infection. The sensitivity, specificity, and likelihood ratio for a positive (LR+) and a negative (LR-) result were calculated. RESULTS: PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.849, 0.880, and 0.884, respectively, with no statistically significant differences. Optimal cut-off values were: PCT > or = 0.65 ng/ml (sensitivity 85 %, specificity 80 %, LR 1 4.25, LR- 0.19), PCR > or = 5 .g/ml (sensitivity 80 %, specificity 95 %, LR 1 16, LR- 0.21), and I/T > or = 0.03 (sensitivity 90 %, specificity 75 %, LR 1 3.6, LR- 0.13). CONCLUSIONS: PCT may be a useful marker for the diagnosis of nosocomial neonatal sepsis. Studies with larger samples are required to compare the accuracy of PCT with that of other markers of sepsis.

Procalcitonina para el diagnóstico de sepsis neonatal de transmisión vertical / Procalcitonin for the diagnosis of neonatal sepsis of vertical transmission

Objetivo: Evaluar la utilidad de la procalcitonina (PCT) para el diagnóstico de sepsis neonatal de transmisión vertical y comparar sus resultados con los marcadores de sepsis más utilizados. Pacientes y métodos: Estudio prospectivo sobre 136 muestras de 69 recién nacidos ingresados en un servicio de neonatología. Se midieron la PCT, proteína C reactiva (PCR), recuento leucocitario e índice de neutrófilos inmaduros/totales (índice I/T). Se construyó el rango de normalidad de la PCT entre 0 y 72 h de vida y se calculó la eficacia diagnóstica de los marcadores de infección estudiados con sus intervalos de confianza del 95 % (IC 95 %). Resultados: Se incluyeron 35 controles, 24 neonatos con procesos no infecciosos y 10 diagnosticados de sepsis (cinco con confirmación bacteriológica). PCT, PCR e índice I/T mostraron capacidad diagnóstica, con áreas bajo la curva COR de 0,696 (p 5 0,009), 0,735 (p 5 0,002) y 0,703 (p 5 0,006), respectivamente, sin diferencias estadísticamente significativas. El rendimiento mejoró a partir de las 24 h de vida para PCT, PCR y recuento leucocitario, con áreas bajo la curva COR de 0,813 (p 5 0,007), 0,826 (p 5 0,005) y 0,841 (p 5 0,003), respectivamente. Globalmente la PCT detectó sepsis de transmisión vertical con sensibilidad del 68,4 % (IC 95 %: 46,0-84,6), especificidad 82,4 % (IC 95 %: 72,2-89,4), cociente de probabilidades del positivo 3,89 (IC 95 %: 2,18-6,96) y cociente de probabilidades del negativo 0,38 (IC 95 %: 0,19-0,76), similares a la PCR. Conclusiones: La PCT puede ser una herramienta útil para el diagnóstico de sepsis de transmisión vertical. Es necesario disponer de estudios con mayor número de pacientes

Objective: To evaluate procalcitonin (PCT) as a diagnostic marker of neonatal sepsis of vertical transmission and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. Patients and Methods: A prospective study was conducted in 136 blood samples from 69 newborn infants admitted to a neonatal department. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured. The PCT reference range of controls from 0 to 72 hours of life was constructed, and the diagnostic efficiency of the tests was calculated, with their 95 % confidence intervals (95 % CI). Results: This study included 35 controls, 24 neonates with noninfectious disorders, and 10 neonates with sepsis (5 with culture-proven sepsis). PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.696 (p 5 0.009), 0.735 (p 5 0.002), and 0.703 (p 5 0.006), respectively, with no statistically significant differences. The accuracy of PCT, CRP, and leukocyte count improved after 24 hours of life with areas under the ROC curve of 0.813 (p 5 0.007), 0.826 (p 5 0.005), and 0.841 (p 5 0.003), respectively. Overall, PCT detected vertically transmitted sepsis with a sensitivity of 68.4 % (95 % CI: 46.0 %-84.6 %), specificity of 82.4 % (95 % CI: 72.2 %-89.4 %), positive likelihood ratio of 3.89 (95 % CI: 2.18 %-6.96 %), and negative likelihood ratio of 0.38 (95 % CI: 0.19 %-0.76 %), similar to those of CRP. Conclusions: PCT may be a useful marker for the diagnosis of vertically transmitted sepsis. Studies with larger sample sizes are required to establish the accuracy of PCT

Procalcitonina para el diagnóstico de sepsis neonatal de origen nosocomial / Procalcitonin for the diagnosis of nosocomial neonatal sepsis

Antecedentes: La sepsis nosocomial supone una de las mayores preocupaciones en las unidades de neonatología y, dada la falta de especificidad de sus síntomas, se hacen necesarias pruebas complementarias muy fiables para orientar el diagnóstico. El objetivo de este estudio es evaluar la utilidad de la procalcitonina (PCT) para el diagnóstico de sepsis neonatal de origen nosocomial y comparar sus resultados con los marcadores de sepsis más utilizados. Pacientes y métodos: Estudio prospectivo realizado en una unidad de cuidados intensivos neonatales. Se incluyeron 20 casos de sepsis nosocomial y 20 controles de entre 4 y 30 días de vida. Se midieron la PCT, proteína C reactiva (PCR), recuento leucocitario e índice de neutrófilos inmaduros/totales (índice I/T) en el momento de la sospecha de sepsis. Se calculó la sensibilidad, especificidad, valores predictivos y cocientes de probabilidades del positivo (CPP) y del negativo (CPN) de los marcadores de infección estudiados. Resultados: PCT, PCR e índice I/T mostraron capacidad diagnóstica, con áreas bajo la curva COR de 0,849, 0,880 y 0,884, respectivamente, sin diferencias estadísticamente significativas. Los puntos de corte óptimos fueron: PCT >= 0,65 ng/ml (sensibilidad 85%; especificidad 80%; CPP 4,25; CPN 0,19), PCR >= 5 mg/ml (sensibilidad 80%; especificidad 95%; CPP 16; CPN 0,21) e índice I/T >= 0,03 (sensibilidad 90%; especificidad 75%; CPP 3,6; CPN 0,13). Conclusiones: La PCT puede ser una herramienta útil para el diagnóstico de sepsis nosocomial en neonatos, aunque es necesario disponer de estudios con mayor número de pacientes para poder comparar su rendimiento con el de otros marcadores de sepsis neonatal

Background: Nosocomial sepsis is a major problem in neonatal units. Because the clinical signs are nonspecific, highly reliable diagnostic markers are required to guide diagnosis. The aim of this study was to evaluate the utility of procalcitonin (PCT) as a diagnostic marker for nosocomial neonatal sepsis, and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. Patients and Methods: Twenty neonates with nosocomial sepsis and 20 controls aged 4-30 days were included in a prospective study performed in a neonatal intensive care unit. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured at onset of signs of infection. The sensitivity, specificity, and likelihood ratio for a positive (LR1) and a negative (LR­) result were calculated. Results: PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.849, 0.880, and 0.884, respectively, with no statistically significant differences. Optimal cut-off values were: PCT >= 0.65 ng/ml (sensitivity 85 %, specificity 80 %, LR 1 4.25, LR­ 0.19), PCR >= 5 mg/ml (sensitivity 80 %, specificity 95 %, LR 1 16, LR­ 0.21), and I/T >= 0.03 (sensitivity 90 %, specificity 75 %, LR 1 3.6, LR­ 0.13). Conclusions: PCT may be a useful marker for the diagnosis of nosocomial neonatal sepsis. Studies with larger samples are required to compare the accuracy of PCT with that of other markers of sepsis

Sepsis nosocomial por Hafnia alvei en una unidad de cuidados intensivos neonatales / Nosocomial Hafnia alvei sepsis in a neonatal intensive care unit

Hafnia alvei es un miembro de la familia Enterobacteriaceae raramente relacionado con procesos infecciosos en pediatría y, de manera excepcional, en el período neonatal. Produce infecciones fundamentalmente como germen oportunista. Los cuadros de bacteriemia se relacionan en su gran mayoría con enfermedades abdominales o inmunodepresión. Presentamos cuatro pacientes con sepsis neonatal nosocomial en pacientes prematuros, sin patología o cirugía abdominal previa, con hemocultivos positivos a H. alvei, tratados en nuestro centro en un corto espacio de tiempo (AU)

[Nosocomial Hafnia alvei sepsis in a neonatal intensive care unit]. / Sepsis nosocomial por Hafnia alvei en una unidad de cuidados intensivos neonatales.

Hafnia alvei is a member of the Enterobacteriaceae family, which is rarely associated with infection in pediatric patients and exceptionally in the neonatal period. Infections caused by this organism are usually opportunistic. H. alvei bacteremias are mostly associated with abdominal disease or immunosuppression. We report four cases of nosocomial sepsis in preterm infants with positive blood cultures to H. alvei that were treated in our institution within a short period of time.

Síndrome de megavejiga-microcolon-hipoperistaltismo intestinal / Megabladder-microcolon-intestinal hypoperistaltism syndrome

El síndrome de megavejiga-microcolon-hipoperistaltismo intestinal es una causa rara, grave y congénita de obstrucción intestinal funcional neonatal que además puede llevar asociadas otras alteraciones. Actualmente sigue siendo difícil el diagnóstico prenatal de certeza y debe hacerse diagnóstico diferencial con problemas obstructivos. Al nacimiento se presenta con clínica de obstrucción intestinal y retención urinaria, precisando de pruebas complementarias para la confirmación diagnóstica. En el manejo de estos pacientes es fundamental el soporte nutricional que en muchas ocasiones se basa en nutrición parenteral durante largos periodos de tiempo. A pesar de la mejoría en la asistencia a estos pacientes, este síndrome sigue presentando una elevada morbilidad y mortalidad siendo el trasplante intestinal una alternativa terapéutica. Se presenta a continuación el caso de un paciente que actualmente tiene 6 meses y recibe nutrición enteral a débito continuo suplementada con nutrición parenteral domiciliaria con buena ganancia ponderal y aceptable calidad de vida (AU)

Neonatal sepsis of nosocomial origin: an epidemiological study from the "Grupo de Hospitales Castrillo".

A prospective multicenter study was designed to assess the frequency, etiology, and mortality of nosocomial neonatal sepsis diagnosed between 1996 and 1997 in the neonatology services of 27 acute-care hospitals in Spain ("Grupo de Hospitales Castrillo"). Nosocomial sepsis is defined in the literature using chronological criteria (> 3-7 days of life at the onset of symptoms); accordingly, there is the possibility of including late-onset maternally acquired sepsis or of excluding early-onset nosocomial sepsis (< 3-7 days of life). For these reasons, in this study, cases of nosocomial sepsis that developed at < or = 3-7 days after birth (early onset) were also recorded and maternally acquired sepsis diagnosed beyond 3-7 days of life were excluded. Using these criteria in a total of 30,993 admissions to the neonatal units of the participating hospitals, the nosocomial sepsis rate was 2.1% with an incidence density of 0.89 per 1000 patient days. Sepsis rate was significantly more frequent among very low birth weight (VLBW) infants (15.6%) than among those weighing > or = 1500 g (1.16%) (P < 0.001). Fifty-eight percent of all isolates were Gram-positive organisms, mainly Staphylococcus epidermidis (42%). Gram-negative organisms were isolated in 29.5% of cases (Escherichia coli and Klebsiella spp. were the most commonly isolated pathogens) and fungal infections in 12%, with absolute predominance of Candida spp. The overall mortality rate was 11.8% and the following subgroups had significantly higher (P < 0.001) mortality rates: sepsis caused by Gram-negative organisms (19% vs. 5.1% in Gram-positive pathogens) and sepsis caused by Pseudomonas aeruginosa (33.3% vs. 9.4% for the total number of sepsis caused by the remaining causative pathogens). Sepsis caused by S. epidermidis showed a significantly lower mortality rate (5.5%) compared with overall sepsis for the remaining etiologies (14.2%) (P < 0.001). In VLBW infants, the mortality rate was significantly higher than in infants weighing > 1500 g (17.3% vs. 6.5%, P < 0.001).

Neonatal sepsis of vertical transmission: an epidemiological study from the "Grupo de Hospitales Castrillo".

A prospective multicenter study was designed to assess the epidemiology of neonatal sepsis of vertical transmission in Spain. The study was carried out by the "Grupo de Hospitales Castrillo" that included the neonatal services of 19 tertiary care (reference) hospitals and 9 secondary care hospitals. Prospective data from infants with culture-proved neonatal sepsis, clinical sepsis and bacteremia were recorded for 1995 to 1997. In a total of 203,288 neonates, proven sepsis was diagnosed in 515 (rate of 2.5 per 1000 live births), clinical sepsis in 724 (rate of 3.6 per 1000 live births), and bacteremia of vertical transmission in 155 (rate of 0.76 per 1000 live births). Very low birth weight (VLBW) infants (< or = 1500 g) showed a significantly higher incidence of confirmed sepsis (26.5 per 1000 live births) and clinical sepsis (32.4 per 1000 live births) than infants weighing > 1500 g. Streptococcus agalactiae was the most frequent causative pathogen in cases of proven sepsis (51%) and bacteremia (33%), but Escherichia coli was the most frequently recovered organism in the VLBW group. The mortality rate of proven sepsis was significantly higher than that of clinical sepsis (8.7% versus 4.3%) (P < 0.01). In the VLBW cohort, there were no significant differences in the mortality rate between proven sepsis and clinical sepsis. In conclusion, clinical sepsis was the most frequent diagnosis, probably related to intrapartum chemoprophylaxis. Streptococcus agalactiae was the most frequent causative pathogen of culture-positive sepsis and bacteremia, whereas E. coli was the most significant in VLBW infants.

Rehospitalization because of respiratory syncytial virus infection in premature infants younger than 33 weeks of gestation: a prospective study. IRIS Study Group.

OBJECTIVE: To collect data on hospitalization for respiratory syncytial virus (RSV) infections and presumptive risk factors for rehospitalization among premature infants in Spain. DESIGN: Observational, prospective, longitudinal, multicenter study. SETTING: Fourteen Spanish neonatal units with an annual birth cohort of 57,000 infants. PATIENTS: All children (n = 680) born < or =32 weeks of gestational age between April 1, 1998, and March 31, 1999, and discharged from the hospital before March 31, 1999, were included in the study. A total of 96 were excluded because of administration of prophylactic treatment (n = 55) or were lost to follow-up (n = 41). Five children died during the study period, but death was related to RSV in only 1 case. METHODS AND MAIN OUTCOME MEASURES: Neonatal and demographic data were recorded at the initial visit. Infants were prospectively followed at monthly intervals up to March 31, 1999. In patients rehospitalized for respiratory disorders, further data about RSV status and morbidity were collected. A comparison was made between children rehospitalized for RSV infection and those who were not. The influence of factors on the probability of rehospitalization for RSV infection was assessed by logistic regression analysis. RESULTS: Of the 584 evaluable patients 118 (20.2%) were rehospitalized for respiratory disease during the study period. The causative pathogen was identified in 89 (75.4%) hospital admissions. Of these 59 (66.3%) were a result of RSV infection in 53 children; 6 were reinfections. In a logistic regression model significant independent prognostic variables included: lower risk of RSV hospitalization with increase gestational age [odds ratio (OR), 0.85; 95% confidence interval (CI), 0.72 to 0.99; P < 0.047]; higher risk with chronic lung disease (OR = 3.1; 95% CI 1.22 to 7.91; P < 0.016); and living with school age siblings (OR = 1.86; 95% CI 1.01 to 3.4; P < 0.048). CONCLUSION: This large descriptive study has enabled us to define the influence of specific risk factors that increase the risk of rehospitalization for RSV infection in preterm infants. Such studies help to define the appropriate role of available prophylactic interventions and establish treatment guidelines.

Estudio prospectivo sobre catéteres epicutáneos en neonatos. Grupo de Hospitales Castrillo / Prospective evaluation of percutaneous central venous silastic catheters in newborn infants. Castrillo hospital group

OBJETIVO: Conocer la situación actual en nuestro país sobre el empleo de catéteres epicutáneos en neonatos, analizando características técnicas y complicaciones infecciosas, mecánicas y locales. MÉTODOS: Entre el 15/7/97 y el 31/12/98, en los servicios de neonatología de los hospitales integrantes del Grupo de Hospitales Castrillo se recogieron de forma prospectiva para su análisis los catéteres epicutáneos colocados en recién nacidos (RN). Cada hospital escogía la duración del período durante el cual se recogían los catéteres, pero se impuso la condición de que durante este tiempo se debían estudiar todos los catéteres colocados. RESULTADOS: Se han analizado 939 catéteres epicutáneo-cava, colocados en 787 RN, totalizando 8.073 días-catéter. De ellos, 826 (88 por ciento) se colocaron a través de venas de extremidad superior, 82 (8,7 por ciento) a través de venas de extremidad inferior y 31 (3,3 por ciento) a través de venas del cuero cabelludo. Fueron colocados en neonatos con amplia variedad de pesos y edades gestacionales, insertándose la mayoría en la primera semana de vida y permaneciendo una media de 7 días (máximo 55 días). Se utilizaron principalmente catéteres de silicona (96,8 por ciento) siendo su colocación poco dificultosa (un 58,7 por ciento al primer intento). La mayoría se retiraron electivamente (61,5 por ciento). Se realizó cultivo de la punta en 872 catéteres (92,8 por ciento) y de ellos, 219 (25,1 por ciento) estaban colonizados. Entre los colonizados, 178 presentaban contaminación del catéter y en 41 se confirmó sepsis relacionada con catéter (SRC). La incidencia de contaminación fue del 20,4 por ciento (178/872) y de sepsis cierta relacionada con catéter del 4,7 por ciento (41/872). Para los 7.744 días-catéter de estos 872, la densidad de incidencia fue de 23 y 5,3 por 1.000 días-catéter para contaminación y sepsis, respectivamente. En la etiología de contaminación y SRC predominaron gérmenes grampositivos, destacando S. epidermidis (71,7 y 50 por ciento, respectivamente). En 205 catéteres aparecieron complicaciones locales o mecánicas, siendo la más frecuente la flebitis (9,5 por ciento), sobre todo en catéteres colocados en extremidad inferior. La obstrucción, la extravasación y la rotura fueron complicaciones infrecuentes. CONCLUSIÓN: La utilización de catéteres epicutáneos es una práctica habitual en las UCIN de nuestro país. Es una técnica de acceso venoso, fácil, segura y eficaz para la administración prolongada de soluciones intravenosas, siendo el principal problema derivado de su uso las infecciones, sobre todo las SRC originadas por S. epidermidis (AU)