Neonatal early-onset Escherichia coli disease. The effect of intrapartum ampicillin.

BACKGROUND: Maternal intrapartum ampicillin has been recommended for the prevention of neonatal group B streptococcal disease. OBJECTIVES: To assess the effect of this practice, if any, on neonatal early-onset Escherichia coli infection and to delineate the clinical characteristics of infected neonates. PATIENTS AND METHODS: All neonates with early-onset E coli infection who were born at Cook County Children's Hospital, Chicago, Ill, from January 1, 1982, through December 31, 1993, were identified from a microbiological register of all neonatal bacteremias and infections. Because intrapartum ampicillin use increased in our hospital since 1988, infection and case fatality rates from 1982 through 1987 (period 1) were compared with data from 1988 through 1993 (period 2). We studied maternal risk factors, clinical characteristics of infected neonates, and microbiological sensitivities of E coli isolates. RESULTS: Early-onset E coli infection was diagnosed in 30 of 61,498 live births. The overall infection rate (0.49 per 1000 live births) did not change significantly during the 2 time periods (0.37 per 1000 live births during period 1 vs 0.62 per 1000 live births during period 2, P = .21; chi 2 test); however, there was an increase in the infection rate in neonates weighing between 1501 and 2500 g. Infected neonates had a clinical syndrome that was indistinguishable from early-onset group B streptococcal infection; respiratory distress was the single most frequent finding in 73% (22/30) infected neonates. An increase in the proportion of infections caused by ampicillin-resistant E coli was observed during period 2 (12/18) compared with period 1 (3/12, P = .03; Fisher exact test). During period 2, 61% (11/18) of mothers of infected neonates received intrapartum ampicillin compared with 17% (2/12; P = .02) during period 1. Overall, a higher proportion of neonates born to ampicillin-treated women had ampicillin-resistant infection (12/13 vs 3/17; P < .001). Mothers of 10 of 15 neonates with ampicillin-resistant infection had received more than 2 doses of intrapartum ampicillin. The difference between the prevalence of intrapartum fever in mothers with sensitive organisms (40%, or 6/15) and resistant organisms (93%, or 14/15) was also significant (P = .003). All 6 early-onset E coli-related deaths were due to ampicillin-resistant organisms; 4 of the 6 mothers received intrapartum ampicillin. CONCLUSIONS: We have shown a shift of early-onset E coli infection from a less fulminant disease caused by ampicillin-sensitive organisms to a more fulminant disease caused by ampicillin-resistant organisms. Increased use of maternal intrapartum ampicillin therapy may account for these changes. In the absence of evidence for group B streptococcal disease, clinicians should consider the possibility of ampicillin-resistant E coli infection in critically ill neonates born to women with a history of intrapartum fever and treatment with intrapartum ampicillin.

Green vomiting in the first 72 hours in normal infants.

From June 1980 to September 1984, forty-five newborns (weight greater than or equal to 2000 g), initially presumed normal, were seen with bilious vomiting in the first 72 hours and were prospectively followed up. Nine (20%) required surgical intervention, five (11%) had nonsurgical obstruction such as meconium plug or left microcolon, and the remaining 31 (69%) had idiopathic bilious vomiting. Infants with idiopathic bilious vomiting had a benign transient course and resumed feedings by 1 week of age; 30 of the 31 had normal or nonspecific findings on initial plain abdominal roentgenogram. Specific findings on the initial plain abdominal roentgenogram were noted in five infants, and four (80%) of these had a lesion requiring surgical intervention; 56% (5/9) of neonates with surgical lesions had normal or nonspecific findings on the plain abdominal roentgenograms. None developed bowel ischemia or midgut infarction secondary to a volvulus as they were identified by contrast studies shortly after the initial episode of bilious vomiting. Although the majority of "normal" neonates with bilious vomiting do not have a surgical lesion, this study indicates that 56% of surgical cases will be missed if contrast studies are not done.

Hypoglycemia and hyperglycemia in tiny infants.

When the maternal supply of glucose is removed, endogenous hepatic glucose production and enteral or parenteral nutrition become the primary source of glucose supply. Because of this, the 1000-gm infant has special problems with glucose homeostasis. This article reviews these particular difficulties.

Penicillin in infants weighing two kilograms or less with early-onset Group B streptococcal disease.

We studied the effect of penicillin on early-onset Group B streptococcal disease over a 52-month period in neonates who were at high risk of infection. Shortly after birth, 1187 neonates weighing 2000 g or less had blood samples taken for cultures and were randomized into an early-treatment group (given intramuscular penicillin G within 60 minutes of birth) or a control group. The incidence of early-onset disease was 20 per 1000 live births (24 of 1187); the number of infants in the early-treatment group who had disease (10 of 589) was similar to that in the control group (14 of 598). The fatality rates were similar in both groups (6 of 10 vs. 8 of 14). Cultures from blood obtained with one hour of birth were positive in 21 of the 24 infants with disease; 22 of the 24 were symptomatic within four hours of birth. Thus, infection was well established before the first hour of postnatal life. At autopsy, gram-positive cocci were seen in lung sections of four infants in whom cultures of blood obtained after treatment had been sterile; this indicates that giving routine antibiotic therapy before culture samples are obtained can obscure bacteriologic diagnosis. We conclude that penicillin given at birth to neonates weighing 2000 g or less does not prevent early-onset streptococcal disease or reduce excess mortality associated with disease.

Absorption of iodine in the neonate following topical use of povidone iodine.

Topical application of povidone iodine on the umbilical cord and normal intact skin of newborn infants resulted in significantly elevated plasma iodine levels. High iodine levels were also found in two neonates who had povidone iodine applied to denuded skin. No significant alteration in thyroid function was seen. The possible toxic manifestations of high plasma iodine levels are discussed.