Retrospective analysis of leukemoid reactions in extremely preterm infants in a tertiary NICU from 2018-2021.

BACKGROUND: Neonatal leukemoid reaction is associated with higher risk of mortality, chronic lung disease and has been associated with chorioamnionitis. Literature on extremely low birth weight infants with leukemoid reaction is limited. OBJECTIVES: The aim of our study was to characterize the maternal and placental factors associated with neonatal leukemoid reaction and to describe outcomes of these ELBW infants. Our objective was to assess if there were maternal factors that would assist the decision-making process regarding the delivery of preterm infants at risk of chorioamnionitis and the sequelae of this inflammatory process. METHODS: This was a retrospective case-control study performed in a single, tertiary Maternity Hospital in Dublin. Two matched controls were identified for each case based on gestation and year of birth and data was collected on both the infants and their mothers. RESULTS: 7 extremely preterm neonates were identified as having a leukemoid reaction, defined as a total white cell count of >50,000 or in the first seven days of life. Baseline characteristics between the groups were similar. The median gestational age in the cases group was 24 + 4 weeks and in the control group was 24 + 1. The mean birthweight was 650 g in the cases group vs. 655 g in the control group. There was a higher percentage of males in the control group, 42.9% vs 28.6% in the cases. The preterm infants with leukemoid reaction had a longer duration of ventilation with a median of 18 days (7.5-23.5 days) compared to 6.5 days (2.8-24.5 days) in the control group. More infants in the leukemoid reaction group required inotropes for hypotension in the first 72 h after delivery (42.9% vs 7.1% in the controls, p value .169). Death or Bronchopulmonary dysplasia (BPD) occurred in 85.7% of the cases identified with a leukemoid reaction vs 71.4% of the controls matched. Median maternal CRP was higher in cases prior to delivery vs the controls (66 vs 18.1 mg/L, p-value = .2151). There was histological evidence of maternal inflammatory response in all cases with fetal inflammatory response in 71% of cases. CONCLUSIONS: Leukemoid reaction in ELBW infants with evidence of maternal and fetal inflammatory response syndrome on placental histology is associated with a longer duration of initial ventilation, increased need for inotropes in the first 72 h after birth, higher rates of death, and BPD. Prospective studies are required to identify potential biomarkers such as proinflammatory cytokines, IL-6, which might aid the decision-making process in delivery.

Enhanced Carbapenemase Producing Enterobacterales (CPE) Screening in a Paediatric Population.

Aims The aim of this period of extended screening (to include those being readmitted to TSCUH if they had been an inpatient in the preceding year) was to determine whether any additional CPE positive patients were identified. Methods Education was given to Clinical Nurse Managers regarding those requiring screening and reinforced at daily handover meetings. Results 917 patients were screened during the four-month period; only two positive patients were identified, who would have been screened under the previous local guidelines. Conclusion The screening of an additional 314 patients (34% increase compared with the same period in the previous year) yielded no positive results, showing that patients whose only risk factor was admission to TSCUH within the previous year do not currently require screening.

Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes.

Diagnosis of rotavirus infection in a vaccinated population: Is a less sensitive immunochromatographic method more suitable for detecting wild-type rotavirus than real-time RT-PCR?

BACKGROUND: Diagnosis of wild-type rotavirus disease may be complicated by the detection of vaccine-derived virus which can be detected in stool samples following immunisation. We evaluate an immunochromatographic assay and real-time RT-PCR to determine which is more suitable for the detection of wild-type rotavirus. OBJECTIVES: To compare the Ct values of wild-type rotavirus and Rotarix determined by real-time RT-PCR. To establish the Ct value corresponding to the limit of detection of the immunochromatographic Combi-Strip method (Coris, BioConcept). STUDY DESIGN: Retrospective review of real-time RT-PCR Ct values was performed on 100 samples tested by a pan-rotavirus assay (n = 50 wild-type, n = 50 Rotarix). Secondly the limit of detection of the Combi-Strip assay was determined by testing; wild-type rotavirus (n = 33, Ct range 6.85-34.26) samples, Rotarix (n = 9, Ct range 20.86-34.26) samples and rotavirus negative (n = 21) samples. RESULTS: The median Ct of 50 wild-type rotavirus was Ct 12.43; range 6.11-32.66 compared with the median of 50 Rotarix, Ct 29.09; range 18.91-35.28, p=<0.0001. The limit of detection of the Combi-Strip method was approximately Ct 18. The 21 rotavirus negative samples were negative by real-time RT-PCR and Combi-Strip. CONCLUSIONS: We found the Ct value was significantly lower, and therefore the viral load higher, for wild-type rotavirus compared to detectable Rotarix. The Combi-Strip assay detects most wild-type infections; however, it lacks sensitivity to detect low-level wild-type rotavirus and, beneficially, is unlikely to detect Rotarix. It is not a more suitable method than real-time RT-PCR when a definitive rotavirus result is required.

Low Yield of Positive Cerebrospinal Fluid (CSF) Culture and Bacterial PCR Tests In Paediatric Patients With A Normal CSF White Cell Count.

The aim was to review paediatric patients who had a positive cerebrospinal fluid culture or bacterial PCR test, yet had a normal CSF white cell count for age. Patients were included if they had a CSF sample sent for culture (between 2005 and 2015) or bacterial PCR (2010-2015), however neurosurgical and neurology patients were excluded. Of the 2,482 patients reviewed, there were 101 patients with laboratory-confirmed bacterial meningitis included, of which 27 were positive by culture and PCR, 26 by culture alone and 48 were positive by PCR only. Eighteen (18%) of these patients had CSF white cell counts within normal range. Only one case with a normal CSF white cell count, where the lumbar puncture was done after six days of antibiotics, was deemed to be clinically significant. Bacterial PCR should not be routinely requested in patients with a normal CSF white cell count, unless their blood culture is positive or unless clinically indicated based on the assessment of a senior paediatrician.

Impact of a rapid molecular test for positive blood cultures from neonatal intensive care patients on clinical management: a retrospective audit.

BACKGROUND: Both Staphylococcus aureus and coagulase negative Staphylococci are common causes of late-onset neonatal sepsis in the neonatal intensive care unit (NICU), usually relating to intravascular access device infections. AIMS: This project aimed to review the impact on antimicrobial treatment and clinical outcome in the NICU setting, of the introduction of the Xpert MRSA/SA BC test (Cepheid, USA) for the identification of staphylococci in blood cultures. METHODS: A retrospective audit was carried out of the pre- and post-intervention periods; the intervention was the introduction of the Xpert MRSA/SA BC test. RESULTS: In total, 88 neonates had positive blood cultures with Staphylococcus spp., comprising 42 neonates in the pre-intervention and 46 in the post-intervention groups. The pre-intervention group had a higher birth weight (1.541 kg vs. 1.219 kg, p = 0.05) and higher platelet count (288 vs. 224 × 109/L, p = 0.05). There was a trend towards a shorter duration of antimicrobial therapy in term infants and in the length of admission; however, this was not statistically significant (p = 0.2). All of the nine infants post-intervention with significant bacteraemia (S. aureus =3, CoNS =6) were changed to the optimal antimicrobial at the time the result was available. CONCLUSIONS: This study shows that the introduction of the Xpert MRSA/SA BC test can lead to a reduction in the length of admission and duration of antimicrobials in term infants; however, the difference was not statistically significant. All nine infants with clinically significant bacteraemia were treated with the appropriate antimicrobial when the Xpert MRSA/SA BC test result was available.

Circulating rotavirus genotypes in the Irish paediatric population prior to the introduction of the vaccination programme.

BACKGROUND: Rotavirus is the leading cause of viral gastroenteritis in children, and it is anticipated that the introduction of the Rotarix™ vaccine (GlaxoSmithKline Biologicals S.A., Rixensart, Belgium) into the Irish immunisation schedule will result in a significant reduction of rotavirus-associated disease. In the pre- and post-vaccination eras, it is important to determine circulating strains of rotavirus to assess vaccine effectiveness, to monitor vaccine failures, and to detect potential emerging strains. AIM: This study was a collaboration between the Temple Street Children's University Hospital (TSCUH), Dublin, and the National Virus Reference Laboratory (NVRL), Dublin, to determine the then circulating rotavirus strains in a paediatric hospital. METHOD: In the 2015/2016 period (July 2015-June 2016) 89 faecal samples from paediatric patients (53 from TSCUH, 36 from other hospitals) were characterised. RESULTS: The results showed G1P[8] to be the predominant genotype (57%), followed by G9P[8] (34%), G4P[8] (6%), G2P[4] (2%), and G12P[8] (1%). CONCLUSION: This distribution of genotypes is comparable to those found in other European countries prior to vaccination suggesting that the vaccine should be highly efficacious in the Irish population.

Group B streptococcal PCR testing in comparison to culture for diagnosis of late onset bacteraemia and meningitis in infants aged 7-90 days: a multi-centre diagnostic accuracy study.

The aim of this study was to compare an in-house real-time PCR assay, with bacterial culture as the reference, for the diagnosis of late onset group B Streptococcal (GBS) disease. This was a retrospective review. All children aged 7-90 days presenting to four paediatric centres that had a blood or CSF sample tested by GBS PCR were included. Of 7,686 blood and 2,495 cerebrospinal fluid (CSF) samples from patients of all ages received for PCR testing, 893 and 859 samples were eligible for the study, respectively. When compared to culture, the sensitivity of blood PCR was 65% (13/20) in comparison to the CSF PCR test which was 100% (5/5). Ten of 23 PCR-positive blood samples and 17 of 22 PCR-positive CSF samples were culture negative. The median threshold Ct values for culture-positive/PCR-positive CSF samples was lower than that of culture-negative/PCR-positive CSF samples (p = 0.08). Clinical details of 17 available cases that were culture negative/PCR positive were reviewed; seven were deemed to be definite cases, eight were probable and two were possible. The results showed that detection of GBS by PCR is useful for CSF samples from infants aged 7-90 days with suspected meningitis; however, analysis of blood samples by PCR is of limited value as a routine screening test for late onset GBS sepsis and should not replace bacterial culture.

Impact of Xpert MRSA/SA blood culture PCR assay on management of positive blood cultures in obstetric patients: a retrospective audit.

BACKGROUND: The Xpert MRSA/SA blood culture assay (Cepheid, USA) is a rapid PCR test which can be used for positive blood cultures where Gram-positive cocci in clusters are seen. It can detect Staphylococcus aureus and also the mecA gene, which encodes for ß-lactam resistance. The assay was introduced into the Rotunda Hospital for positive blood cultures to allow earlier detection of MRSA and methicillin susceptible S. aureus. AIM: To assess the impact of the Xpert MRSA/SA blood culture assay on the management of obstetric patients with a positive blood culture where Gram-positive cocci in clusters were seen. The main outcome measures were duration of intravenous antimicrobials and length of admission. METHODS: Pre-intervention and post-intervention groups were identified relating to whether or not the test was in use at the time. A standardised form was used to retrospectively review the medical notes and laboratory results. RESULTS: There were 35 obstetric patients with positive blood cultures with Gram-positive cocci in clusters in the pre-intervention group and 22 cases in the post-intervention group. All 22 positive blood cultures in the post-intervention period were correctly identified. The antimicrobial duration was reduced from a median of 55.5-43.5 h and length of admission reduced from a median of 66.5-56 h (Mann-Whitney U value = 161, p = 0.46 and U value = 256, p = 0.15, respectively). CONCLUSION: This study has shown a reduction in the median duration of intravenous antimicrobials and admission; however, larger multi-centre studies are needed to evaluate this potential benefit further.

Population pharmacokinetics of teicoplanin in children.

Teicoplanin is frequently administered to treat Gram-positive infections in pediatric patients. However, not enough is known about the pharmacokinetics (PK) of teicoplanin in children to justify the optimal dosing regimen. The aim of this study was to determine the population PK of teicoplanin in children and evaluate the current dosage regimens. A PK hospital-based study was conducted. Current dosage recommendations were used for children up to 16 years of age. Thirty-nine children were recruited. Serum samples were collected at the first dose interval (1, 3, 6, and 24 h) and at steady state. A standard 2-compartment PK model was developed, followed by structural models that incorporated weight. Weight was allowed to affect clearance (CL) using linear and allometric scaling terms. The linear model best accounted for the observed data and was subsequently chosen for Monte Carlo simulations. The PK parameter medians/means (standard deviation [SD]) were as follows: CL, [0.019/0.023 (0.01)] × weight liters/h/kg of body weight; volume, 2.282/4.138 liters (4.14 liters); first-order rate constant from the central to peripheral compartment (Kcp), 0.474/3.876 h(-1) (8.16 h(-1)); and first-order rate constant from peripheral to central compartment (Kpc), 0.292/3.994 h(-1) (8.93 h(-1)). The percentage of patients with a minimum concentration of drug in serum (Cmin) of <10 mg/liter was 53.85%. The median/mean (SD) total population area under the concentration-time curve (AUC) was 619/527.05 mg · h/liter (166.03 mg · h/liter). Based on Monte Carlo simulations, only 30.04% (median AUC, 507.04 mg · h/liter), 44.88% (494.1 mg · h/liter), and 60.54% (452.03 mg · h/liter) of patients weighing 50, 25, and 10 kg, respectively, attained trough concentrations of >10 mg/liter by day 4 of treatment. The teicoplanin population PK is highly variable in children, with a wider AUC distribution spread than for adults. Therapeutic drug monitoring should be a routine requirement to minimize suboptimal concentrations. (This trial has been registered in the European Clinical Trials Database Registry [EudraCT] under registration number 2012-005738-12.).

Emergence of carbapenem-resistant Enterobacteriaceae in a UK paediatric hospital.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae are an emerging global infection threat. However, there are few data describing their clinical importance in children. AIM: This retrospective study reviewed the prevalence and resistance mechanisms of carbapenem-resistant Enterobacteriaceae grown from clinical and surveillance samples in a large tertiary referral children's hospital in the UK. METHODS: Carbapenem-resistant Enterobacteriaceae were sought in specimens submitted for diagnostic and surveillance purposes at Alder Hey Children's NHS Foundation Trust, Liverpool, between September 2011 and August 2012. Mechanisms of resistance were identified using phenotypic and/or molecular methods. Variable number tandem repeat profiling was used to type carbapenemase-producing strains. FINDINGS: During the 12-month study period, carbapenem-resistant Enterobacteriaceae were recovered from 24 patients. Five isolates were from clinical diagnostic specimens whereas 19 of 421 patients had positive rectal surveillance swabs (4.5%). Of the 24 isolates, seven (all Klebsiella spp.) harboured carbapenemases: three had blaKPC and four blaNDM, whereas 17 had resistance due to combinations of AmpC or extended-spectrum ß-lactamase activity plus impermeability. CONCLUSION: Carbapenem-resistant Enterobacteriaceae and, in particular, those with carbapenemases, are an emerging infection problem in a major paediatric hospital in the UK. Active surveillance is required to monitor and control their spread.

BK virus (BKV) plasma dynamics in patients with BKV-associated hemorrhagic cystitis following allogeneic stem cell transplantation.

INTRODUCTION: The use of real-time polymerase chain reaction testing in the investigation of BK virus (BKV)-associated disease has been widely studied in renal transplant recipients; however, far less research has been done in this area with respect to the plasma BK viral load dynamics of BKV hemorrhagic cystitis (BKV-HC) in hematopoietic stem cell transplant recipients. AIM: The aim of this study was to examine the BK viral load dynamics in plasma samples collected from patients post transplant who had laboratory-confirmed BKV-HC. METHODS: Patients who developed BK viremia were compared with patients who did not develop viremia, and a statistical comparison of risk factors for viremia was performed. Seventeen patients were included in this study. Urine samples from the day of BKV diagnosis were available in 13 of the 17 cases. In total, 154 archived plasma samples from around the time of the BKV-HC event were also included in the study from these 17 patients. RESULTS: The median time from transplantation to the onset of detectable viremia was 68 days. The median viral load in the 13 urine samples was 1.8 × 10(8) copies/mL, which was significantly higher than the median viral load in the 38 positive plasma samples of 6.6 × 10(2) copies/mL (Mann-Whitney test, U = 16, P < 0.001). CONCLUSION: The lymphocyte count on the day of the positive BKV test was significantly lower in patients with BKV viremia than in patients with no viremia (P = 0.02) and also the white cell and platelet counts were lower on the day of the first positive BKV test. Although there is not inter-patient consistency as regards correlation between urinary BK viral loads and severity of clinical BKV-HC, in individual patients the decline in viral load in plasma did correlate with clinical recovery.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012.

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

A case of disseminated miliary tuberculosis in a five-year-old child.

A five-year old girl was referred, by the local area medical officer, as she had a positive Mantoux test and a chest x-ray consistent with miliary tuberculosis. She had initially been identified three months previously as a contact of a case of open pulmonary tuberculosis. A CT scan of the brain at the time of presentation showed multiple intracranial tuberculomae. A CT Brain scan three months into the treatment regime showed a significant reduction in the number and size of nodules indicating a favourable response to treatment. This case emphasises the importance of rapid tracing of paediatric tuberculosis contacts, if serious complications and their consequences are to be avoided.

Quality assurance of electrosurgical devices: a manufacturer's view.

The safe and effective use of electrosurgical devices is a complex activity dependent on a wide array of people and factors. Among the significant factors involved is the quality designed and built into the products. Quality assurance of electrosurgical devices includes the well-known quality control functions of inspection and test, in addition to a host of other activities: requirements definition, product design, assembly, product evaluation, regulatory compliance, product information, user training, and customer service. This article delineates some of the mechanisms that a manufacturer employs to ensure that the products he or she offers to the health care customer are safe and effective and possess the high quality level that their intended use requires.