Factors influencing antimicrobial resistance and outcome of Gram-negative bloodstream infections in children.

OBJECTIVE: The aim of this study was to collect data about pediatric Gram-negative bloodstream infections (BSI) to determine the factors that influence multidrug resistance (MDR), clinical course and outcome of children affected by Gram-negative sepsis. METHODS: In this observational, prospective, multicenter study we collected cases of pediatric Gram-negative BSI during a 2-year period. We analyzed epidemiological, microbiological and clinical factors that associated with acquisition of MDR infections and outcome. RESULTS: One-hundred and thirty-five BSI episodes were analyzed. Median age of children was 0.5 years (IQR 0.1-6.17, range 0-17 years). Predominant bacteria were Enterobacteriaceae (68.3 %), and Pseudomonas spp. (17.9 %). Multidrug resistance was detected in 45/134 cases (33.6 %), with the highest rates in Escherichia coli, Enterobacter and Pseudomonas spp. Acquisition of MDR pathogens was significantly associated with prior cephalosporin treatment, older age, admission to hemato-oncology unit, polymicrobial infections, higher rate of development of septic shock, and multiple organ failures. All-cause mortality was 17.9 %. Presence of septic shock at presentation and parenteral nutrition were associated with higher mortality. Pseudomonas spp., and Enterobacter spp. BSIs had the highest rate of mortality. Inappropriate empiric antibiotic therapy was more frequent in MDR patients, although not significantly associated with poor outcome. CONCLUSION: Rates of multidrug resistance and mortality in children with Gram-negative bloodstream infections remain high in our settings. Empiric broad-spectrum antibiotics and combination therapy could be recommended, especially in children with malignant diseases, patients admitted to the PICU, and for cases with septic shock, who have higher mortality risk.

Evaluation of an open access software for calculating glucose variability parameters of a continuous glucose monitoring system applied at pediatric intensive care unit.

BACKGROUND: Continuous Glucose Monitoring (CGM) has become an increasingly investigated tool, especially with regards to monitoring of diabetic and critical care patients. The continuous glucose data allows the calculation of several glucose variability parameters, however, without specific application the interpretation of the results is time-consuming, utilizing extreme efforts. Our aim was to create an open access software [Glycemic Variability Analyzer Program (GVAP)], readily available to calculate the most common parameters of the glucose variability and to test its usability. METHODS: The GVAP was developed in MATLAB® 2010b environment. The calculated parameters were the following: average area above/below the target range (Avg. AUC-H/L); Percentage Spent Above/Below the Target Range (PATR/PBTR); Continuous Overall Net Glycemic Action (CONGA); Mean of Daily Differences (MODD); Mean Amplitude of Glycemic Excursions (MAGE). For verification purposes we selected 14 CGM curves of pediatric critical care patients. Medtronic® Guardian® Real-Time with Enlite® sensor was used. The reference values were obtained from Medtronic®(')s own software for Avg. AUC-H/L and PATR/PBTR, from GlyCulator for MODD and CONGA, and using manual calculation for MAGE. RESULTS: The Pearson and Spearman correlation coefficients were above 0.99 for all parameters. The initial execution took 30 minutes, for further analysis with the Windows® Standalone Application approximately 1 minute was needed. CONCLUSIONS: The GVAP is a reliable open access program for analyzing different glycemic variability parameters, hence it could be a useful tool for the study of glycemic control among critically ill patients.

Effects of pH, lactate, hematocrit and potassium level on the accuracy of continuous glucose monitoring (CGM) in pediatric intensive care unit.

BACKGROUND: Continuous glucose monitoring (CGM) originally was developed for diabetic patients and it may be a useful tool for monitoring glucose changes in pediatric intensive care unit (PICU). Its use is, however, limited by the lack of sufficient data on its reliability at insufficient peripheral perfusion. We aimed to correlate the accuracy of CGM with laboratory markers relevant to disturbed tissue perfusion. PATIENTS AND METHODS: In 38 pediatric patients (age range, 0-18 years) requiring intensive care we tested the effect of pH, lactate, hematocrit and serum potassium on the difference between CGM and meter glucose measurements. Guardian® (Medtronic®) CGM results were compared to GEM 3000 (Instrumentation laboratory®) and point-of-care measurements. The clinical accuracy of CGM was evaluated by Clarke Error Grid -, Bland-Altman analysis and Pearson's correlation. We used Friedman test for statistical analysis (statistical significance was established as a p < 0.05). RESULTS: CGM values exhibited a considerable variability without any correlation with the examined laboratory parameters. Clarke, Bland-Altman analysis and Pearson's correlation coefficient demonstrated a good clinical accuracy of CGM (zone A and B = 96%; the mean difference between reference and CGM glucose was 1,3 mg/dL, 48 from the 780 calibration pairs overrunning the 2 standard deviation; Pearson's correlation coefficient: 0.83). CONCLUSIONS: The accuracy of CGM measurements is independent of laboratory parameters relevant to tissue hypoperfusion. CGM may prove a reliable tool for continuous monitoring of glucose changes in PICUs, not much influenced by tissue perfusion, but still not appropriate for being the base for clinical decisions.

[Maybe it hurts more than we think! Neonatal pain]. / Talán mégis jobban fáj, mint gondolnánk! újszülöttkori fájdalom.

Neonatal pain is often undertreated. This is based on the assumption that because of the immature nervous system and the lack of the myelinisation preterm and newborn does not feel pain. It is confirmed by a number of articles that the fetus and neonate can experience and respond to painful events. This publication gives a brief overview of the ontogeny of the pain, short- and long-term postnatal consequences, as well as the perception of the possibility of a particularly frail child population: premature infants and neonates, based on animal and human studies.

[Role of continuous subcutaneous glucose monitoring in intensive care]. / A folyamatos szubkután glükózmonitorizálás szerepe az intenzív terápiában.

Critical care associated with stress hyperglycaemia has gained a new view in the last decade since the demonstration of the beneficial effects of strong glycaemic control on the mortality in intensive care units. Strong glycaemic control may, however, induce hypoglycaemia, resulting in increased mortality, too. Pediatric population has an increased risk of hypoglycaemia because of the developing central nervous system. In this view there is a strong need for close monitoring of glucose levels in intensive care units. The subcutaneous continuous glucose monitoring developed for diabetes care is an alternative for this purpose instead of regular blood glucose measurements. It is important to know the limitations of subcutaneous continuous glucose monitoring in intensive care. Decreased tissue perfusion may disturb the results of subcutaneous continuous glucose monitoring, because the measurement occurs in interstitial fluid. The routine use of subcutaneous continuous glucose monitoring in intensive care units is not recommended yet until sufficient data on the reliability of the system are available. The Medtronic subcutaneous continuous glucose monitoring system is evaluated in the review partly based on the authors own results.

[Hyperglycemia and mortality in critically ill children]. / Hyperglykaemia és mortalitás kritikus állapotú gyermekeknél.

UNLABELLED: Several pathologic conditions are accompanied by stress-induced hyperglycemia in non-diabetic individuals which influences mortality and morbidity. AIMS: Prospective studies in adults support that glycemic control is an independent predictor of survival and normoglycemia has a beneficial effect on the outcome of patients. Few data are available in children, however a retrospective study documented significant correlation between mortality and duration, intensity and peak value of hyperglycemia. In the present study, the authors investigated the relationship between blood glucose level and pathological process in a multidisciplinary pediatric intensive care department retrospectively. RESULTS: It has been shown that highest blood glucose values were associated with fatal outcome independent of diagnosis (mean: 14,38 mmol/l) and with septicemia independent of final outcome (mean: 13,97 mmol/l). Patients with fatal outcome were hyperglycemic during the total duration (mean: 7,59 mmol/l) and on the last day (mean: 7,00 mmol/l) of treatment. Patients who survived had significantly lower blood glucose over the whole duration (mean: 6,52 mmol/l; p < 0,01) and on the last day of treatment (mean: 5,28 mmol/l; p < 0,01) than those who died. Percent of treatment days with blood glucose > = 6,1 mmol/l was significantly lower in case of survival as compared with fatal cases (42,68 vs. 74.07 %; p < 0,01) and the highest rate was observed in those with fatal septcemia (mean: 76,52 %). CONCLUSIONS: These data support that, similarly to adults, critical condition in children induces sustained hyperglycemia and higher peak values and longer duration of elevated blood glucose are associated with higher mortality rate. Septicemia proved to be potent inductor of abnormalities of carbohydrate metabolism.

[New therapeutic possibilities for uncontrolled bleeding]. / Uj terápiás lehetóség az uralhatatlan vérzések csillapítására.

Recombinant factor VIIa (rFVIIa) enhances the haemostasis limited to the site of injury without systemic activation of the coagulation cascade. rFVIIa has been found to enhance thrombin generation in impaired coagulation and thrombocyta function. rFVIIa has been successfully used to treat uncontrolled nontraumatic, traumatic, surgical and thrombocytopenic bleeding. Authors present the cases of three pediatric patients, who received rFVIIa in order to reduce the uncontrolled traumatic, surgical, nontraumatic thrombocytopenic and coagulopathic bleeding. Based on the data of literature authors present the supposed, complex mechanism of rFVIIa and the experiences connected with clinical use.