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Patel AD, Casini G, Hagan JL, Debuyserie A, Vogel AM, Gollins L, Hair AB, Fernandes CJ, Premkumar MH. Factors associated with enteral autonomy after reanastomosis in infants with intestinal failure and ostomy: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:74-81. [PMID: 37872873 DOI: 10.1002/jpen.2570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 10/04/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND To determine variables associated with outcomes in infants with intestinal failure (IF) and ostomy following reanastomosis (RA). METHODS A single-center, descriptive cohort study of 120 infants with IF and a stoma from January 2011 to December 2020 with subsequent RA during initial hospitalization. The primary outcome was achievement of enteral autonomy (EA) following RA. Other outcomes were duration of hospital stay, and mortality. Penalized logistic regression and linear regression were used for data analysis. RESULTS The median gestational age was 26 weeks, and the median birth weight was 890 g. Three infants died. The median duration between ostomy creation and RA was 80 days (interquartile range; 62.5, 100.5). For each additional day of discontinuity, the odds of EA decreased by 2% (odds ratio [OR] = 0.980; 95% confidence interval [CI]: 0.962, 0.999; P = 0.038), and death increased by 4.2% (OR = 1.042; 95% CI: 1.010, 1.075; P = 0.009). For each additional mL/kg/day of enteral feeds at RA, the odds of EA increased by 7.5% (OR = 1.075; 95% CI: 1.027, 1.126, P = 0.002) and duration of hospital stay decreased by 0.35 days (slope coefficient = -0.351; 95% CI: -0.540, -0.163; P < 0.001). CONCLUSION Shorter duration of intestinal discontinuity and enteral nutrition before RA could positively influence EA and duration of stay in infants with IF and ostomy following RA.
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Affiliation(s)
- Arjun D Patel
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Gina Casini
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Anne Debuyserie
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Laura Gollins
- Division of Neonatology, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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Garg PM, Paschal JL, Ansari MAY, Block D, Inagaki K, Weitkamp JH. Clinical impact of NEC-associated sepsis on outcomes in preterm infants. Pediatr Res 2022; 92:1705-1715. [PMID: 35352003 DOI: 10.1038/s41390-022-02034-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine risk factors and outcomes of necrotizing enterocolitis (NEC)-associated sepsis in infants with NEC. METHODS A retrospective review comparing demographic and clinical information in infants with and without NEC-associated sepsis (defined as positive blood culture at the time of NEC onset). RESULTS A total of 209 infants with medical (n = 98) and surgical NEC (n = 111) had a median gestational age of 27 weeks (IQR 25; 30.5) and a median birth weight of 910 g [IQR 655; 1138]. Fifty of 209 (23.9%) infants had NEC-associated sepsis. Infants with NEC-associated sepsis had lower median GA (26.4 vs. 27.4 weeks; p = 0.01), lower birth weight (745 vs. 930 g; p = 0.009), were more likely mechanically ventilated [p < 0.001], received dopamine [p < 0.001], had more evidence of acute kidney injury [60% vs. 38.4%, p = 0.01], longer postoperative ileus (16 [13.0; 22.0] vs. 12 [8; 16] days; p = 0.006), higher levels of C-reactive protein, lower platelet counts, longer hospitalization compared to infants without NEC-associated sepsis. On multivariate regression, cholestasis was an independent risk factor for NEC-associated sepsis (OR 2.94; 95% CI 1.1-8.8, p = 0.038). CONCLUSION NEC-associated sepsis was associated with greater hemodynamic support, acute kidney injury, longer postoperative ileus, and hospitalization on bivariate analysis, and cholestasis was associated with higher odds of sepsis on multi regression analysis. IMPACT NEC-associated sepsis was present in 24% of infants with NEC. Gram-positive bacteria, Gram-negative bacteria, and Candida were found in 15.3%, 10.5%, and 2.8% of cases, respectively. Infants with NEC-associated sepsis had a greater inflammatory response (CRP levels), received more blood transfusion before NEC onset, frequently needed assisted ventilation ionotropic support, and had acute kidney injury after NEC onset. NEC infants with Gram-negative sepsis had higher portal venous gas, received more platelet transfusions before NEC onset, and had higher CRP levels and lower median lymphocyte counts at 24 h after NEC onset than those with Gram-positive sepsis.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Jaslyn L Paschal
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Md Abu Yusuf Ansari
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Danielle Block
- Department of Pediatrics/Neonatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kengo Inagaki
- Department of Pediatrics/Infectious Disease, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics/Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Flannery DD, Puopolo KM, Hansen NI, Sánchez PJ, Stoll BJ. Neonatal infections: Insights from a multicenter longitudinal research collaborative. Semin Perinatol 2022; 46:151637. [PMID: 35864010 PMCID: PMC10959576 DOI: 10.1016/j.semperi.2022.151637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
For more than 30 years, the Neonatal Research Network (NRN) has conducted studies addressing the epidemiology of neonatal infections, including incidence, microbiology, maternal and neonatal risk factors, associated clinical findings, and outcomes. These studies have provided clinicians and policymakers critical data needed to inform national guidance for infection risk assessment and support daily practice. Further, NRN studies have prompted research into optimal approaches to infection diagnosis, treatment, and antimicrobial stewardship. In this article, we summarize the key findings of NRN infection-related studies, with an emphasis on those published in 2000 or later.
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Affiliation(s)
- Dustin D Flannery
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Karen M Puopolo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nellie I Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Barbara J Stoll
- Department of Pediatrics, Emory University, Atlanta, GA, USA
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4
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Onufer EJ, Aladegbami B, Imai T, Seiler K, Bajinting A, Courtney C, Sutton S, Bustos A, Yao J, Yeh CH, Sescleifer A, Wang LV, Guo J, Warner BW. EGFR in enterocytes & endothelium and HIF1α in enterocytes are dispensable for massive small bowel resection induced angiogenesis. PLoS One 2020; 15:e0236964. [PMID: 32931498 PMCID: PMC7491746 DOI: 10.1371/journal.pone.0236964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Short bowel syndrome (SBS) results from significant loss of small intestinal length. In response to this loss, adaptation occurs, with Epidermal Growth Factor Receptor (EGFR) being a key driver. Besides enhanced enterocyte proliferation, we have revealed that adaptation is associated with angiogenesis. Further, we have found that small bowel resection (SBR) is associated with diminished oxygen delivery and elevated levels of hypoxia-inducible factor 1-alpha (HIF1α). Methods We ablated EGFR in the epithelium and endothelium as well as HIF1α in the epithelium, ostensibly the most hypoxic element. Using these mice, we determined the effects of these genetic manipulations on intestinal blood flow after SBR using photoacoustic microscopy (PAM), intestinal adaptation and angiogenic responses. Then, given that endothelial cells require a stromal support cell for efficient vascularization, we ablated EGFR expression in intestinal subepithelial myofibroblasts (ISEMFs) to determine its effects on angiogenesis in a microfluidic model of human small intestine. Results Despite immediate increased demand in oxygen extraction fraction measured by PAM in all mouse lines, were no differences in enterocyte and endothelial cell EGFR knockouts or enterocyte HIF1α knockouts by POD3. Submucosal capillary density was also unchanged by POD7 in all mouse lines. Additionally, EGFR silencing in ISEMFs did not impact vascular network development in a microfluidic device of human small intestine. Conclusions Overall, despite the importance of EGFR in facilitating intestinal adaptation after SBR, it had no impact on angiogenesis in three cell types–enterocytes, endothelial cells, and ISEMFs. Epithelial ablation of HIF1α also had no impact on angiogenesis in the setting of SBS.
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Affiliation(s)
- Emily J. Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Bola Aladegbami
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Toru Imai
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
- Department of Electrical Engineering, Caltech Optical Imaging Laboratory, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States of America
| | - Kristen Seiler
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Adam Bajinting
- Saint Louis University School of Medicine, St. Louis, MO, United States of America
| | - Cathleen Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Stephanie Sutton
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Aiza Bustos
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Junjie Yao
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Cheng-Hung Yeh
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Anne Sescleifer
- Saint Louis University School of Medicine, St. Louis, MO, United States of America
| | - Lihong V. Wang
- Department of Electrical Engineering, Caltech Optical Imaging Laboratory, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States of America
| | - Jun Guo
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
- * E-mail:
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Smazal AL, Massieu LA, Gollins L, Hagan JL, Hair AB, Premkumar MH. Small Proportion of Low-Birth-Weight Infants With Ostomy and Intestinal Failure Due to Short-Bowel Syndrome Achieve Enteral Autonomy Prior to Reanastomosis. JPEN J Parenter Enteral Nutr 2020; 45:331-338. [PMID: 32364291 DOI: 10.1002/jpen.1847] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND It is challenging to provide optimum nutrition in low-birth-weight (LBW) infants with short-bowel syndrome (SBS) and ostomy. This study aims to evaluate the clinical course of LBW infants with SBS and ostomy in response to enteral feeds, recognize characteristics associated with achievement of enteral autonomy prior to reanastomosis, and evaluate associated short-term outcomes. METHODS A retrospective analysis of 52 LBW neonates with intestinal failure (IF) caused by SBS and ostomy treated in a neonatal intensive care unit from 2012 to 2018 was performed. Clinical characteristics and short-term outcomes were studied in relation to the location of the ostomy and the success with enteral feeding achieved prior to reanastomosis. RESULTS Of the 52 infants with SBS, jejunostomy, ileostomy, and colostomy were present in 9, 40, and 3 infants, respectively. Fourteen (26.92%) infants achieved enteral autonomy transiently, and 7 (13.46%) sustained until reanastomosis. All 9 infants with jejunostomy were parenteral nutrition dependent, compared with 22 with ileostomy and none with colostomy (P = 0.002). Infants who achieved enteral autonomy showed lower incidence of cholestasis (P = 0.038) and better growth velocity (P = 0.02) prior to reanastomosis. CONCLUSIONS A minority of LBW infants with SBS and ostomy achieved enteral autonomy prior to reanastomosis. Distal ostomy (ileostomy and colostomy), reduced cholestasis, and better growth were associated with achievement of enteral autonomy. Our report highlights the challenges in establishing enteral autonomy in LBW infants with IF and ostomy, and the feasibility of that approach in a minority of patients, with tangible benefits.
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Affiliation(s)
- Anne L Smazal
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - L Adriana Massieu
- Department of Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Laura Gollins
- Department of Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph L Hagan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Heath M, Buckley R, Gerber Z, Davis P, Linneman L, Gong Q, Barkemeyer B, Fang Z, Good M, Penn D, Kim S. Association of Intestinal Alkaline Phosphatase With Necrotizing Enterocolitis Among Premature Infants. JAMA Netw Open 2019; 2:e1914996. [PMID: 31702803 PMCID: PMC6902776 DOI: 10.1001/jamanetworkopen.2019.14996] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Necrotizing enterocolitis (NEC) in preterm infants is an often-fatal gastrointestinal tract emergency. A robust NEC biomarker that is not confounded by sepsis could improve bedside management, lead to lower morbidity and mortality, and permit patient selection in randomized clinical trials of possible therapeutic approaches. OBJECTIVE To evaluate whether aberrant intestinal alkaline phosphatase (IAP) biochemistry in infant stool is a molecular biomarker for NEC and not associated with sepsis. DESIGN, SETTING, AND PARTICIPANTS This multicenter diagnostic study enrolled 136 premature infants (gestational age, <37 weeks) in 2 hospitals in Louisiana and 1 hospital in Missouri. Data were collected and analyzed from May 2015 to November 2018. EXPOSURES Infant stool samples were collected between 24 and 40 or more weeks postconceptual age. Enrolled infants underwent abdominal radiography at physician and hospital site discretion. MAIN OUTCOMES AND MEASURES Enzyme activity and relative abundance of IAP were measured using fluorometric detection and immunoassays, respectively. After measurements were performed, biochemical data were evaluated against clinical entries from infants' hospital stay. RESULTS Of 136 infants, 68 (50.0%) were male infants, median (interquartile range [IQR]) birth weight was 1050 (790-1350) g, and median (IQR) gestational age was 28.4 (26.0-30.9) weeks. A total of 25 infants (18.4%) were diagnosed with severe NEC, 19 (14.0%) were suspected of having NEC, and 92 (66.9%) did not have NEC; 26 patients (19.1%) were diagnosed with late-onset sepsis, and 14 (10.3%) had other non-gastrointestinal tract infections. For severe NEC, suspected NEC, and no NEC samples, median (IQR) fecal IAP content, relative to the amount of IAP in human small intestinal lysate, was 99.0% (51.0%-187.8%) (95% CI, 54.0%-163.0%), 123.0% (31.0%-224.0%) (95% CI, 31.0%-224.0%), and 4.8% (2.4%-9.8%) (95% CI, 3.4%-5.9%), respectively. For severe NEC, suspected NEC, and no NEC samples, median (IQR) enzyme activity was 183 (56-507) μmol/min/g (95% CI, 63-478 μmol/min/g) of stool protein, 355 (172-608) μmol/min/g (95% CI, 172-608 μmol/min/g) of stool protein, and 613 (210-1465) μmol/min/g (95% CI, 386-723 μmol/min/g) of stool protein, respectively. Mean (SE) area under the receiver operating characteristic curve values for IAP content measurements were 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of severe NEC, 0.97 (0.02) (95% CI, 0.93-1.00; P < .001) at time of suspected NEC, 0.52 (0.07) (95% CI, 0.38-0.66; P = .75) at time of sepsis, and 0.58 (0.08) (95% CI, 0.42-0.75; P = .06) at time of other non-gastrointestinal tract infections. Mean (SE) area under the receiver operating characteristic curve values for IAP activity were 0.76 (0.06) (95% CI, 0.64-0.86; P < .001), 0.62 (0.07) (95% CI, 0.48-0.77; P = .13), 0.52 (0.07) (95% CI, 0.39-0.67; P = .68), and 0.57 (0.08) (95% CI, 0.39-0.69; P = .66), respectively. CONCLUSIONS AND RELEVANCE In this diagnostic study, high amounts of IAP protein in stool and low IAP enzyme activity were associated with diagnosis of NEC and may serve as useful biomarkers for NEC. Our findings indicated that IAP biochemistry was uniquely able to distinguish NEC from sepsis.
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Affiliation(s)
- Maya Heath
- Department of Pediatrics and Neonatology, Louisiana State University School of Medicine, Children’s Hospital of New Orleans, New Orleans
| | - Rebecca Buckley
- Department of Biochemistry and Molecular Biology, Louisiana State University School of Medicine and Health Sciences Center, New Orleans
| | - Zeromeh Gerber
- Department of Pediatrics and Neonatology, Louisiana State University School of Medicine, Children’s Hospital of New Orleans, New Orleans
| | - Porcha Davis
- Department of Biochemistry and Molecular Biology, Louisiana State University School of Medicine and Health Sciences Center, New Orleans
| | - Laura Linneman
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis Children’s Hospital, St Louis, Missouri
| | - Qingqing Gong
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis Children’s Hospital, St Louis, Missouri
| | - Brian Barkemeyer
- Department of Pediatrics and Neonatology, Louisiana State University School of Medicine, Children’s Hospital of New Orleans, New Orleans
| | - Zhide Fang
- Department of Biostatistics, Louisiana State University School of Public Health, New Orleans
| | - Misty Good
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis Children’s Hospital, St Louis, Missouri
| | - Duna Penn
- Department of Pediatrics and Neonatology, Louisiana State University School of Medicine, Children’s Hospital of New Orleans, New Orleans
| | - Sunyoung Kim
- Department of Biochemistry and Molecular Biology, Louisiana State University School of Medicine and Health Sciences Center, New Orleans
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Abstract
Necrotizing enterocolitis is a serious complication of prematurity that is associated with an increased risk for adverse neurodevelopmental outcome secondary to a complex relationship between various morbidities that increase the risk for central nervous system injury. Affected infants are exposed to a variety of circulating cytokines known to be associated with white matter injury. These infants also have an increased risk of secondary blood stream infections and nutritional compromise.
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Affiliation(s)
- Ira Adams-Chapman
- Department of Pediatrics, Division of Neonatology, Emory University School of Medicine, Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30303, USA.
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Bloodstream Infections in Patients With Intestinal Failure Presenting to a Pediatric Emergency Department With Fever and a Central Line. Pediatr Emerg Care 2017; 33:e140-e145. [PMID: 27455342 PMCID: PMC5259554 DOI: 10.1097/pec.0000000000000812] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Previous small studies have found a high occurrence of bloodstream infections (BSIs) in patients with intestinal failure, and these rates are higher than reported rates in other pediatric populations with central lines. The primary study objective was to describe the occurrence of BSIs in patients with intestinal failure who present to the pediatric emergency department (ED) with fever. METHODS This 5-year retrospective chart review included febrile patients with intestinal failure and central lines who presented to the Children's Hospital of Pittsburgh ED between 2006 and 2011. Each febrile episode was analyzed at the visit level. RESULTS During the study, 72 patients with 519 febrile episodes were identified. Central blood cultures were obtained in 93% (480/519) of episodes and 69% (330/480) were positive. Of all BSIs, 38% (124/330) were polymicrobial, 32% (105/330) were a single gram-positive organism, 25% (84/330) were a single gram-negative organism, and 5% (17/330) were a single fungal organism. Of the bacterial pathogens, 48% (223/460) were gram-negative. Overall, 60% were enteric organisms. CONCLUSIONS Pediatric patients with intestinal failure and central lines have a high occurrence of BSIs with 69% of cultures positive in this study of ED febrile episodes. In contrast to reports in other populations with central lines, BSI occurrence in patients with intestinal failure and fever is higher and larger proportions are gram-negative and enteric organisms. For these patients, we recommend central and peripheral blood cultures, empiric broad spectrum antibiotics targeting gram-negative and enteric organisms, and hospital admission.
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Infection Risk Reduction in the Intensive Care Nursery: A Review of Patient Care Practices That Impact the Infection Risk in Global Care of the Hospitalized Neonates. J Perinat Neonatal Nurs 2016; 30:139-47. [PMID: 27104605 DOI: 10.1097/jpn.0000000000000172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonates are at high risk for developing an infection during their hospital stay in the neonatal intensive care unit. Increased risk occurs because of immaturity of the neonate's immune system, lower gestational age, severity of illness, surgical procedures, and instrumentation with life support devices such as vascular catheters. Neonates become colonized with bacteria prior to or at delivery and also during their hospital stay. They can then become infected with those bacteria if there is a breakdown in the primary defenses such as tissue injury due to skin breakdown, nasal erosion, or trauma to the respiratory tract. Neonates are also at high risk for bacterial translocation due to the altered permeability of the intestinal mucosa, loss of commensal flora, and bacterial overgrowth. The unit-based neonatal care team must implement global care delivery and safety practices, utilize published care guidelines, know and apply evidence-based practices from collaborative quality improvement efforts and other sources, and use auditing and monitoring practices that can identify risks and lead to better practice options to prevent infections. This article presents several aspects of global neonatal care delivery, including vascular access, which may reduce the risk of systemic infection during the hospitalization.
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Heida FH, Hulscher JBF, Schurink M, van Vliet MJ, Kooi EMW, Kasper DC, Pones M, Bos AF, Benkoe TM. Bloodstream infections during the onset of necrotizing enterocolitis and their relation with the pro-inflammatory response, gut wall integrity and severity of disease in NEC. J Pediatr Surg 2015; 50:1837-41. [PMID: 26259559 DOI: 10.1016/j.jpedsurg.2015.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/26/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bacterial involvement is believed to play a pivotal role in the development and disease outcome of NEC. However, whether a bloodstream infection (BSI) predisposes to NEC (e.g. by activating the pro-inflammatory response) or result from the loss of gut wall integrity during NEC development is a longstanding question. OBJECTIVE We hypothesize that the occurrence of a BSI plays a complementary role in the pathogenesis of NEC. The first aim of the study was to correlate the occurrence of a BSI during the early phase of NEC with intestinal fatty acid-binding protein (I-FABP) levels, as a marker for loss of gut wall integrity owing to mucosal damage, and Interleukin (IL)-8 levels, as a biomarker for the pro-inflammatory cascade in NEC. The second aim of the study was to investigate the relation between the occurrence of a BSI and disease outcome. MATERIAL AND METHODS We combined data from prospective trials from two large academic pediatric surgical centers. Thirty-eight neonates with NEC, 5 neonates with bacterial sepsis, and 14 controls were included. RESULTS BSIs occurred in 10/38 (26%) neonates at NEC onset. No association between the occurrence of BSIs and I-FABP levels in plasma (cohort 1: median 11ng/mL (range 0.8-298), cohort 2: median 6.8ng/mL (range 1.3-15)) was found in NEC patients (cohort 1: p=0.41; cohort 2: p=0.90). In addition, the occurrence of BSIs did not correlate with IL-8 (median 1562pg/mL (range 150-7,500); p=0.99). While the occurrence of a BSI was not correlated with Bell's stage (p=0.85), mortality was higher in patients with a BSI (p=0.005). CONCLUSION The low incidence of BSIs and the absent association of both the markers for loss of gut wall integrity and the pro-inflammatory response during the early phase of NEC, support the hypothesis that the presence of a BSI does not precede NEC.
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Affiliation(s)
- F H Heida
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands; Department of Medical Microbiology, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands.
| | - J B F Hulscher
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands
| | - M Schurink
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands
| | - M J van Vliet
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands
| | - E M W Kooi
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands
| | - D C Kasper
- Department of Analytics, Medical University of Vienna, Austria
| | - M Pones
- Department of Pediatric Surgery, Research Core Unit for Pediatric Biochemistry, Medical University of Vienna, Austria
| | - A F Bos
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center, Groningen, the Netherlands
| | - T M Benkoe
- Department of Pediatric Surgery, Research Core Unit for Pediatric Biochemistry, Medical University of Vienna, Austria
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Miko BA, Kamath SS, Cohen BA, Jeon C, Jia H, Larson EL. Epidemiologic Associations Between Short-Bowel Syndrome and Bloodstream Infection Among Hospitalized Children. J Pediatric Infect Dis Soc 2015; 4:192-7. [PMID: 26336089 PMCID: PMC4554204 DOI: 10.1093/jpids/piu079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 07/02/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Children with short bowel syndrome (SBS) suffer from strikingly high rates of morbidity and mortality, due in part to their susceptibility to life-threatening infectious diseases. Few large, multisite studies have evaluated patient-specific factors associated with bacteremia in hospitalized children with and without SBS. METHODS We conducted a case-control study to examine the epidemiological associations between SBS and bloodstream infections (BSI) in hospitalized children. Pediatric BSI cases and controls were selected from a prospective cohort study conducted at 3 New York City hospitals. RESULTS Among 40 723 hospital admissions of 30 179 children, 1047 diagnoses of BSI were identified. A total of 64 children had a diagnosis of SBS. BSI was identified frequently among hospitalizations for children admitted with SBS (n = 207/450, 46%) compared to hospitalizations for children without the condition (n = 840/40 273, 2.1%, P < .001). While this population represented only 0.2% of our overall cohort, it accounted for nearly 20% of all hospital admissions with BSI. Multivariable analysis identified 8 factors significantly associated with pediatric hospitalizations with BSI. These included a diagnosis of SBS (odds ratio [OR] 19.0), ages 1-5 years (OR 1.33), presence of a non-Broviac-Hickman central venous catheter (OR 6.36), immunosuppression (OR 0.53), kidney injury (OR 6.67), organ transplantation (OR 4.44), admission from a skilled nursing facility (OR 2.66), and cirrhosis (OR 7.23). CONCLUSIONS While several clinical characteristics are contributory to the risk of BSI in children, SBS remains the single strongest predictor. Further research into the mediators of this risk will be essential for the development of prevention strategies for this vulnerable population.
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Affiliation(s)
| | - Suma S. Kamath
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, College of Physicians and Surgeons
| | - Bevin A. Cohen
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
| | - Christie Jeon
- Center for Cancer Prevention and Control Research, Department of Health Policy and Management, University of California, Los Angeles
| | - Haomiao Jia
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York
| | - Elaine L. Larson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
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12
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Elfvin A, Dinsdale E, Wales PW, Moore AM. Low birthweight, gestational age, need for surgical intervention and gram-negative bacteraemia predict intestinal failure following necrotising enterocolitis. Acta Paediatr 2015; 104:771-6. [PMID: 25762289 DOI: 10.1111/apa.12997] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/30/2015] [Accepted: 03/09/2015] [Indexed: 11/30/2022]
Abstract
AIM Necrotising enterocolitis (NEC) is associated with high morbidity and mortality. The aim of this study was to identify predictors of intestinal failure (IF), morbidity and mortality following NEC. METHODS We performed a retrospective study of all neonates treated for NEC stage II or greater at a tertiary referral NICU between 2000 and 2009. Demographic data, need for surgery, residual bowel length and rates of bacteraemia, cholestasis, IF and mortality were analysed. RESULTS During the 10-year period, 301 patients were referred with NEC and 152 had surgical intervention. Overall mortality was 32%. Of the 230 infants who survived >42 days, 97 (42%) had IF at 42 days, decreasing to 15% at >90 days. The rate of IF was significantly higher in the surgical group than the medical group (OR 2.04, 95% CI, 1.25-3.35, p < 0.004), but 23% of the medically treated infants with NEC also developed IF. There was a significant relationship between IF and gram-negative bacteraemia, the need for surgery, cholestasis, liver failure and mortality. CONCLUSION Intestinal failure occurred in a significant proportion of infants with NEC. Predictors for IF among infants with NEC were low birthweight, low gestational age, need for surgical intervention and gram-negative bacteraemia.
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Affiliation(s)
- Anders Elfvin
- Divisions of Neonatology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
- Department of Pediatrics; Institute of Clinical Sciences; Sahlgrenska Academy; Gothenburg University; Gothenburg Sweden
| | - Elsa Dinsdale
- Divisions of Neonatology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Paul W. Wales
- Pediatric Surgery; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Aideen M. Moore
- Divisions of Neonatology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
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13
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Fujioka WK, Cowles RA. Infectious complications following serial transverse enteroplasty in infants and children with short bowel syndrome. J Pediatr Surg 2015; 50:428-30. [PMID: 25746702 DOI: 10.1016/j.jpedsurg.2014.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/19/2014] [Accepted: 07/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Serial transverse enteroplasty (STEP) lengthens and tapers dilated small bowel in patients with short bowel syndrome (SBS). Previous reports document encouraging outcomes with regard to tolerance for enteral nutrition (EN) and complications appear related to the re-operative nature of many cases and to the presence of multiple staple lines. However, infectious complications following STEP have not been examined. Since infections, especially catheter-related blood stream infections (CRBSI), are considered detrimental in infants and children with SBS, we sought to define the frequency and outcomes of peri-operative infections associated with STEP. METHODS All children with SBS who underwent a STEP between 2004 and 2012 were indentified and their medical records were reviewed. Patients were considered candidates for a STEP if they had dilated small bowel and failure to advance enteral nutrition. For the purpose of this study, infections occurring within a 14-day period after STEP were considered procedure-related and were the focus of the study. RESULTS A total of 18 patients underwent 23 STEP procedures. Primary diagnoses included intestinal atresia, gastroschisis, necrotizing enterocolitis, and midgut volvulus. After the STEP, eight patients (35%) developed CRBSI, three developed wound infections, and two had urinary tract infections. Organisms isolated from either blood, wound or urine cultures included gram-positive cocci, gram-negative rods, and yeast. Perioperative antibiotics were administered in all cases with cefoxitin (43%) and piperacillin/tazobactam (30%) being most common. Neither antibiotic appeared superior in reducing the incidence of CRBSI. In three patients with persistent bacteremia despite adequate antibiotic therapy, a 74% ethanol lock resulted in negative blood cultures in all cases. Only one central venous catheter required replacement acutely for persistent fungemia. CONCLUSION STEP can improve enteral tolerance. In this fragile patient population, however, STEP carries a documented infectious burden. The optimal antibiotic prophylaxis and the role of ethanol locking in patients undergoing STEP require further study.
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Affiliation(s)
- Wendy K Fujioka
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Robert A Cowles
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, 10032, USA; Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.
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14
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The value of routine evaluation of gastric residuals in very low birth weight infants. J Perinatol 2015; 35:57-60. [PMID: 25166623 PMCID: PMC5446673 DOI: 10.1038/jp.2014.147] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/30/2014] [Accepted: 06/16/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Little information exists regarding gastric residual (GR) evaluation prior to feedings in premature infants. The purpose of this study was to compare the amount of feedings at 2 and 3 weeks of age, number of days to full feedings, growth and incidence of complications between infants who underwent RGR (routine evaluation of GR) evaluation versus those who did not. STUDY DESIGN Sixty-one premature infants were randomized to one of two groups. Group 1 received RGR evaluation prior to feeds and Group 2 did not. RESULT There was no difference in amount of feeding at 2 (P=0.66) or 3 (P=0.41) weeks of age, growth, days on parenteral nutrition or complications. Although not statistically significant, infants without RGR evaluation reached feeds of 150 ml kg(-1) per day 6 days earlier and had 6 fewer days with central venous access. CONCLUSION RESULTs suggest RGR evaluation may not improve nutritional outcomes in premature infants.
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15
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Coffin SE, Klieger SB, Duggan C, Huskins WC, Milstone AM, Potter-Bynoe G, Raphael B, Sandora TJ, Song X, Zerr DM, Lee GM. Central line-associated bloodstream infections in neonates with gastrointestinal conditions: developing a candidate definition for mucosal barrier injury bloodstream infections. Infect Control Hosp Epidemiol 2014; 35:1391-9. [PMID: 25333434 DOI: 10.1086/678410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop a candidate definition for central line-associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants. DESIGN Multicenter retrospective cohort study. SETTING Neonatal intensive care units from 14 US children's hospitals and pediatric facilities. METHODS A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure. RESULTS During 2009-2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P < .01). CONCLUSIONS While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.
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Affiliation(s)
- Susan E Coffin
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, and Department of Infection Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Galloway DP, Troutt ML, Kocoshis SA, Gewirtz AT, Ziegler TR, Cole CR. Increased Anti-Flagellin and Anti-Lipopolysaccharide Immunoglobulins in Pediatric Intestinal Failure: Associations With Fever and Central Line-Associated Bloodstream Infections. JPEN J Parenter Enteral Nutr 2014; 39:562-8. [PMID: 24898211 DOI: 10.1177/0148607114537073] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 05/01/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) pose a significant challenge in the lives of patients with intestinal failure (IF). We hypothesized that plasma immunoglobulins against flagellin (FLiC) and lipopolysaccharide (LPS) would be able to differentiate CLABSIs from nonbacterial febrile episodes and that levels would increase with infection and decline following appropriate antibiotic treatment. MATERIALS AND METHODS Patients with IF, due to short bowel syndrome, between the ages of 3 months and 4 years of age, were recruited at Cincinnati Children's Hospital Medical Center. Anti-FLiC and anti-LPS plasma antibody levels were measured in 13 children with IF at baseline, during febrile events, and also following treatment with antibiotics. These were also measured in 11 healthy children without IF who were recruited as controls. RESULTS Plasma anti-FLiC IgA levels increased during febrile episodes in all patients with IF (baseline mean of 1.10 vs febrile episode mean of 1.32 optical density units, respectively; P = .046). Neither plasma anti-FLiC nor anti-LPS IgA or IgG levels distinguished CLABSI from nonbacterial febrile episodes compared with baseline levels. Compared with controls, patients with IF had significantly higher plasma levels of anti-FLiC and anti-LPS IgA at baseline. CONCLUSION Plasma anti-FLiC IgA antibody levels rise during febrile episodes but do not differentiate between nonbacterial febrile illnesses and CLABSIs in pediatric IF. However, the upregulation of these antibodies in IF suggests the baseline systemic presence of Gram-negative bacterial products.
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Affiliation(s)
- David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Misty L Troutt
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Samuel A Kocoshis
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrew T Gewirtz
- Center for Inflammation, Immunity, and Infection, Department of Biology, Georgia State University, Atlanta, Georgia
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University, Atlanta, Georgia
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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17
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Segal I, Kang C, Albersheim SG, Skarsgard ED, Lavoie PM. Surgical site infections in infants admitted to the neonatal intensive care unit. J Pediatr Surg 2014; 49:381-4. [PMID: 24650461 PMCID: PMC5756080 DOI: 10.1016/j.jpedsurg.2013.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/31/2013] [Accepted: 08/02/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Surgical interventions are common in infants admitted to the neonatal intensive care unit (NICU). Despite our awareness of the broad impact of surgical site infection (SSI), there are little data in neonates. Our objective was to determine the rate and clinical impact of SSI in infants admitted to the NICU. METHODS Provincial population-based study of infants admitted to a tertiary care NICU. SSI, explicitly defined, was included if it occurred within 30 days of a skin/mucosal-breaking surgical intervention. RESULTS Among 724 infants who underwent 1039 surgical interventions very low birth weight (VLBW) infants were over-represented. The overall SSI rate was 4.3 per 100 interventions [CI 95% 3.2 to 5.7], up to 19 per 100 dirty interventions (wound class 4) [CI 95% 4.0 to 46]. Rates were higher in infants following gastroschisis closure (13 per 100 infants [CI 95% 5.8 to 24]), whereas they were generally low following a ligation of a ductus arteriosus. Infants with SSI required longer hospitalization after adjusting for co-morbidities (p<0.001). CONCLUSIONS Data from this relatively large contemporary study suggest that SSI rates in the NICU setting are more comparable to the pediatric age group. However, VLBW infants and those undergoing gastroschisis closure represent high risk groups.
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Affiliation(s)
- Ilan Segal
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Christine Kang
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1
| | - Susan G. Albersheim
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
| | - Erik D. Skarsgard
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Department of Surgery, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Pascal M. Lavoie
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
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18
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Abstract
NEC remains a major concern for neonatologists, surgeons, and gastroenterologists due to its high morbidity and mortality. These infants often have poor developmental outcome, and contribute to significant economic burden resulting in marked stress in these families. By developing and adhering to strict feeding protocols, encouraging human milk feeding preferably from the infant's mother, use of probiotics, judicious antibiotic use, instituting blood transfusion protocols, the occurrence of NEC may possibly be reduced. However, because of its multifactorial etiology, it cannot be completely eradicated in the NICUs, particularly in the extremely premature infants. Ongoing surveillance of NEC and quality improvement projects may be beneficial.
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19
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Bizzarro MJ, Ehrenkranz RA, Gallagher PG. Concurrent bloodstream infections in infants with necrotizing enterocolitis. J Pediatr 2014; 164:61-6. [PMID: 24139563 DOI: 10.1016/j.jpeds.2013.09.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 08/16/2013] [Accepted: 09/06/2013] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the incidence, microbiology, risk factors, and outcomes related to bloodstream infections (BSIs) concurrent with the onset of necrotizing enterocolitis (NEC). STUDY DESIGN We performed a retrospective review of all cases of NEC in a single center over 20 years. BSI was categorized as "NEC-associated" if it occurred within 72 hours of the diagnosis of NEC and "post-NEC" if it occurred >72 hours afterwards. Demographics, hospital course data, microbiologic data, and outcomes were compared via univariate and multivariate analyses. RESULTS NEC occurred in 410 infants with mean gestational age and birth weight of 29 weeks and 1290 g, respectively; 158 infants were diagnosed with at least one BSI; 69 (43.7%) with NEC-associated BSI, and 89 (56.3%) with post-NEC BSI. Two-thirds of NEC-associated BSI were due to gram-negative bacilli compared with 31.9% of post-NEC BSI (OR: 4.27; 95% CI: 2.02, 9.03) and 28.5% of all BSI in infants without NEC (OR: 5.02; 95% CI: 2.82, 8.96). Infants with NEC-associated BSI had higher odds of requiring surgical intervention (aOR: 3.51; 95% CI: 1.98, 6.24) and death (aOR: 2.88; 95% CI: 1.39, 5.97) compared with those without BSI. CONCLUSIONS BSI is a common, underappreciated complication of NEC occurring concurrent with the onset of disease and afterwards. The microbiologic etiology of NEC-associated BSI is different from post-NEC and late-onset BSI in infants without NEC with a predominance of gram-negative bacilli. Infants with NEC-associated BSI are significantly more likely to die than those with post-NEC BSI and NEC without BSI.
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT.
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20
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Prospective Cohort Study of the Outcome of and Risk Factors for Intravascular Catheter-Related Bloodstream Infections in Children With Intestinal Failure. JPEN J Parenter Enteral Nutr 2013; 38:625-30. [DOI: 10.1177/0148607113517716] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/01/2013] [Indexed: 11/15/2022]
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21
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Abstract
Neonatal sepsis continues to be a common and significant health care burden, especially in very-low-birth-weight infants (VLBW <1500 g). Though intrapartum antibiotic prophylaxis has decreased the incidence of early-onset group B streptococcal infection dramatically, it still remains a major cause of neonatal sepsis. Moreover, some studies among VLBW preterm infants have shown an increase in early-onset sepsis caused by Escherichia coli. As the signs and symptoms of neonatal sepsis are nonspecific, early diagnosis and prompt treatment remains a challenge. There have been a myriad of studies on various diagnostic markers like hematological indices, acute phase reactants, C-reactive protein, procalcitonin, cytokines, and cell surface markers among others. Nonetheless, further research is needed to identify a biomarker with high diagnostic accuracy and validity. Some of the newer markers like inter α inhibitor proteins have shown promising results thereby potentially aiding in early detection of neonates with sepsis. In order to decrease the widespread, prolonged use of unnecessary antibiotics and improve the outcome of the infants with sepsis, reliable identification of sepsis at an earlier stage is paramount.
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Affiliation(s)
- Birju A Shah
- Instructor of Pediatrics; Neonatal-Perinatal Medicine; Warren Alpert Medical School of Brown University; Women & Infants Hospital of Rhode Island; Providence, RI USA
| | - James F Padbury
- Pediatrician-in-Chief, Professor of Pediatrics; Warren Alpert Medical School of Brown University; Women & Infants Hospital of Rhode Island; Providence, RI USA
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22
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Abstract
Current evidence highlights the importance of developing a healthy intestinal microbiota in the neonate. Many aspects that promote health or disease are related to the homeostasis of these intestinal microbiota. Their delicate equilibrium could be strongly influenced by the intervention that physicians perform as part of the medical care of the neonate, especially preterm infants. As awareness of the importance of the development and maintenance of these intestinal flora increase and newer molecular techniques are developed, it will be possible to provide better care of infants with interventions that will have long-lasting effects.
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23
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Abstract
Necrotizing enterocolitis (NEC) primarily affects premature infants. It is less common in term and late preterm infants. The age of onset is inversely related to the postmenstrual age at birth. In term infants, NEC is commonly associated with congenital heart diseases. NEC has also been associated with other anomalies. More than 85% of all NEC cases occur in very low birth weight infants or in very premature infants. Despite incremental advances in our understanding of the clinical presentation and pathophysiology of NEC, universal prevention of this disease continues to elude us even in the twenty-first century.
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MESH Headings
- Age of Onset
- Disease Management
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/therapy
- Humans
- Infant, Newborn
- Infant, Premature/physiology
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/therapy
- Intestinal Perforation/diagnosis
- Intestines/diagnostic imaging
- Intestines/microbiology
- Intestines/physiopathology
- Pneumoperitoneum/diagnosis
- Prevalence
- Radiography
- Risk
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Affiliation(s)
- Renu Sharma
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine at Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
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24
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Abstract
Prematurely born infants are at increased risk for infection throughout their hospitalization. Various developmentally regulated processes involving the central nervous and respiratory systems may be disrupted by the proinflammatory state associated with infection, resulting in an increased risk for death, chronic lung disease, and adverse neurodevelopmental outcome. This review summarizes the current understanding of the long-term impact of infection and/or inflammation in preterm infants, including the risks associated with perinatal infection, early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis.
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Affiliation(s)
- Ira Adams-Chapman
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30303, USA.
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