Impact of active surveillance and decolonization strategies for methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit.

OBJECTIVE: To assess the impact of active surveillance and decolonization strategies on methicillin-resistant Staphylococcus aureus (MRSA) infection rates in a NICU. STUDY DESIGN: MRSA infection rates were compared before (2014-2016) and during (2017-2022) an active surveillance program. Eligible infants were decolonized with chlorohexidine gluconate (CHG) bathing and/or topical mupirocin. Successful decolonization and rates of recolonization were assessed. RESULTS: Fifty-two (0.57%) of 9 100 hospitalized infants had invasive MRSA infections from 2014 to 2022; infection rates declined non-significantly. During the 6-year surveillance program, the risk of infection was 16.9-times [CI95 8.4, 34.1] higher in colonized infants than uncolonized infants. Those colonized with mupirocin-susceptible MRSA were more likely successfully decolonized (aOR 9.7 [CI95 4.2, 22.5]). Of 57 infants successfully decolonized who remained hospitalized, 34 (60%) became recolonized. CONCLUSIONS: MRSA infection rates did not significantly decline in association with an active surveillance and decolonization program. Alternatives to mupirocin and CHG are needed to facilitate decolonization.

A Multifunctional, Low Cost and Sustainable Neonatal Database System.

Continuous improvement in the clinical performance of neonatal intensive care units (NICU) depends on the use of locally relevant, reliable data. However, neonatal databases with these characteristics are typically unavailable in NICUs using paper-based records, while in those using electronic records, the inaccuracy of data and the inability to customize commercial data systems limit their usability for quality improvement or research purposes. We describe the characteristics and uses of a simple, neonatologist-centered data system that has been successfully maintained for 30 years, with minimal resources and serving multiple purposes, including quality improvement, administrative, research support and educational functions. Structurally, our system comprises customized paper and electronic components, while key functional aspects include the attending-based recording of diagnoses, integration into clinical workflows, multilevel data accuracy and validation checks, and periodic reporting on both data quality and NICU performance results. We provide examples of data validation methods and trends observed over three decades, and discuss essential elements for the successful implementation of this system. This database is reliable and easily maintained; it can be developed from simple paper-based forms or used to supplement the functionality and end-user customizability of existing electronic medical records. This system should be readily adaptable to NICUs in either high- or limited-resource environments.

Epidemiology, risk factors, and applicability of CDC definitions for healthcare-associated bloodstream infections at a level IV neonatal ICU.

OBJECTIVES: We studied the epidemiology of primary bloodstream infections (BSIs), secondary BSIs, and central line-associated BSIs (CLABSIs) and applicability of CDC definitions for primary sources of infection causing secondary BSIs in patients in the neonatal ICU. STUDY DESIGN: We classified healthcare-associated BSIs (HABSIs) as primary BSIs, secondary BSIs, and CLABSIs using CDC surveillance definitions and determined their overall incidence and incidence among different gestational age strata. We assessed the applicability of CDC definitions for infection sources causing secondary BSIs. RESULTS: From 2010 to 2019, 141 (32.7%), 202 (46.9%), and 88 (20.4%) HABSIs were classified as primary BSIs, secondary BSIs, and CLABSIs, respectively; all declined during the study period (all p < 0.001). Gestational age <28 weeks was associated with increased incidence of all HABSI types. CDC criteria for site-specific primary sources were met in 137/202 (68%) secondary BSIs. CONCLUSIONS: Primary and secondary BSIs were more common than CLABSIs and should be prioritized for prevention.

Fungal cutaneous microbiome and host determinants in preterm and term neonates.

BACKGROUND: The neonatal cutaneous mycobiome has not been characterized in preterm infants. Invasive fungal infections in preterm neonates are associated with high mortality. The immaturity of the preterm skin predisposes neonates to invasive infection by skin colonizers. We report the clinical and host determinants that influence the skin mycobiome. METHODS: Skin swabs from the antecubital fossa, forehead, and gluteal region of 15 preterm and 15 term neonates were obtained during the first 5 weeks of life. The mycobiome was sequenced using the conserved pan-fungal ITS2 region. Blood samples were used to genotype immune modulating genes. Clinical metadata was collected to determine the clinical predictors of the abundance and diversity of the skin mycobiome. RESULTS: The neonatal mycobiome is characterized by few taxa. Alpha diversity of the mycobiome is influenced by antibiotic exposure, the forehead body site, and the neonatal intensive care unit (NICU) environment. Beta diversity varies with mode of delivery, diet, and body site. The host determinants of the cutaneous microbiome include single-nucleotide polymorphisms in TLR4, NLRP3,CARD8, and NOD2. CONCLUSION: The neonatal cutaneous mycobiome is composed of few genera and is influenced by clinical factors and host genetics, the understanding of which will inform preventive strategies against invasive fungal infections.

Trifurcation of superficial brachial artery: a rare case with its clinico-embryological implications.

Literatures on vasculature of upper limbs are crammed with reports of distinctly deviant version of normally prevalent vessels having modified origins, altered branching and odd courses. A unique anatomical variation in vascular pattern was observed during routine dissection of right upper limb in gross anatomy laboratory, AIIMS, New Delhi, India. The brachial artery was placed superficial to median nerve in the arm and therefore it was called superficial brachial artery. In the cubital fossa, 2.8 cm distal to intercondylar line of elbow joint, this superficial brachial artery terminated by trifurcation into radial, common interosseous and ulnar branches. Strikingly the ulnar branch, after its origin ran superficially over the median nerve and epitrochlear superficial flexor group of muscles of forearm in succession for the initial third of its course in the forearm, consequently it was addressed as superficial ulnar artery. The existence of superficial brachial artery in place of normal brachial artery, its termination by trifurcation into radial, common interosseous and superficial ulnar arteries with remarkably different courses, leads to confusing disposition of structures in the arm, cubital fossa and in the forearm and collectively makes this myriad of anatomical variations even rarer. The clinico-embryological revelations for combination of these unconventional observations, apprises and guides the specialized medical personnel attempting blind and invasive procedures in brachium and ante-brachium. This case report depicts the anatomical perspective and clinical implications on confronting a rare variant vasculature architecture pattern of upper limb.

A rare conglomeration of neurovascular variations in the brachium-antebrachium: clinico-embryological elucidation.

During routine dissection in left upper limb in an elderly male cadaver, variations in the arterial and neural pattern were noticed. The undersized brachial artery divided terminally into radial and ulnar artery at a distance of 15.4 cm from the tip of coracoid process, proximal to its usual division in cubital fossa. Additionally, the superior and inferior ulnar collateral artery instead of arising from the brachial artery, emanated from ulnar artery. The course of the median nerve also deserves a brief mention as it crossed the brachial artery from medial to lateral side to position itself laterally in the midbrachium. Coursing further, it shifted from lateral to medial side over the ulnar artery in the distal third of arm, thus placing itself medial to ulnar artery in the cubital fossa. There was also a communication between a medial offshoot of the musculocutaneous nerve and the median nerve 3 cm from the bifurcation of the brachial artery. Although the variations in the origin, termination, course and branching pattern of upper limb vessels and nerves are well documented, but the multitude of disparity in morphology with confusing neurovascular assembly put together in the same limb denotes an outstanding case. An attempt has been made to correlate the present anatomical variations with embryological aspects. Moreover, the clinical inferences of such variations are discussed for planning, performing and analyzing invasive and noninvasive clinical procedures in this region.

Visual acuity outcomes after deep anterior lamellar keratoplasty: a case-control study.

AIM: To compare visual outcomes between deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK). Secondarily to compare refractive outcomes, complications and graft survival between the three cohorts. METHODS: Retrospective case-control study evaluating visual acuity outcomes (VA) following DALK with complete Descemet's baring (DALKa) (modified Anwar big bubble technique--51 eyes), pre-descemetic anterior lamellar keratoplasty (DALKm) (manual technique--52 eyes) and PK (103 eyes) with mean follow-up of 13.6, 19.3 and 18.6 months, respectively. RESULTS: The common indications for surgery were corneal scars (36.4%), keratoconus (28.6%) and corneal dystrophies (13.6%). A best-corrected VA of 6/7.5 or better was achieved in 19.4% (PK), 21.6% (DALKm) and 38.5% (DALKa) of cases (p=0.02), and eyes that underwent DALKa had significantly better visual outcomes than PK (p=0.03). Complications following PK were glaucoma (15%), endothelial rejection (12%) and epithelial problems (11%); in the lamellar group, glaucoma (9%), epithelial problems (5%) and Descemet's detachment (3%) were more common. The 2-year estimated probability of graft survival was 90% for PK, 98% for DALKm and 100.0% for DALKa (p=0.35). CONCLUSIONS: Lamellar keratoplasty with complete baring of the Descemet's membrane (DALKa) gave significantly better visual outcomes compared to PK or pre-descemetic ALK and should be the preferred from of corneal replacement in corneal disorders with healthy endothelium.

Syphilitic uveitis: an Asian perspective.

AIM: To examine the clinical manifestations of syphilitic uveitis in a population and review trends in incidence at a tertiary referral centre. METHODS: A retrospective, non-comparative interventional case series of 22 consecutive patients with syphilitic uveitis who were managed in the Ocular Inflammation and Immunology Services of the Singapore National Eye Centre between 1995 and 2006. RESULTS: Twenty-two patients (mean age 52.7 years, range 18-78) with a positive serum fluorescent treponemal antibody absorption test (100%) and negative HIV serology were reviewed. Non-granulomatous anterior uveitis was the commonest presenting finding (18/29 eyes, 62.06%). Posterior uveitis was seen in four (13.7%), intermediate uveitis in three (10.3%) and panuveitis was seen in eight (27.5%) eyes at presentation. Vitritis (19 eyes, 65.4%) was the commonest posterior segment finding. The majority (86.4%) had latent syphilis at the time of ocular involvement. An increasing trend in the number of cases of ocular syphilis in the past decade was not observed. CONCLUSIONS: Despite resurgence in infectious syphilis, this centre did not see a dramatic rise in cases of syphilitic uveitis. Ocular syphilis presented most frequently as a non-granulomatous inflammation. Therefore, syphilis serology should be sought even for cases of anterior uveitis.

Characterization of the complete genome of influenza A (H5N1) virus isolated during the 2006 outbreak in poultry in India.

An outbreak of highly pathogenic avian influenza A (H5N1) virus in poultry was reported from Nandurbar and Jalgaon districts of Maharashtra and adjoining areas of Uchhal in Gujarat and Burhanpur in Madhya Pradesh in India from January to April, 2006. In the present study, the full genome of two previously uncharacterized strains of H5N1 viruses isolated at the National Institute of Virology (NIV), Pune, from post-mortem tissues of chicken collected from Navapur, Nandurbar district during the outbreak, has been presented. All the genes belong to clade 2.2 of the Z genotype and are close to the 2006 isolates from Iran, Afghanistan, Mongolia, Italy, and Krasnodar. In a study reported earlier, based on the partial gene sequences of HA, the authors (Pattnaik et al.) hypothesized that the viruses in Jalgaon and Navapur, causing outbreaks 12 days apart, were introduced at different times from different sources. However, our Navapur isolates are closer to the isolate reported from Jalgaon than that from Navapur. Molecular markers suggest that the isolates are sensitive to both drugs Oseltamivir and Amantadine. Amino acid residues responsible for pathogenesis, glycosylation, and receptor binding have also been discussed. The relationship between the Indian viruses and those in the East Africa/West-Asia flyway of migratory birds and the position of Nandurbar in this route suggests that the viruses in India may have been introduced through migratory birds although the role of trade as a possible route of introduction of the virus cannot be ruled out.