Sepsis in young infants with congenital heart disease

Incidence and predictors of mortality among neonates with congenital heart disease in Ethiopia: a retrospective cohort study

BACKGROUND

Neonatal mortality poses a significant public health challenge in sub-Saharan Africa, with congenital heart disease emerging as the leading cause of morbidity and mortality among neonates, especially in countries like Ethiopia. Despite efforts to reduce neonatal mortality rates, Ethiopia continues to experience an increased mortality rate, particularly among neonates with congenital heart disease. This study aims to investigate the incidence and predictors of mortality in this vulnerable population within Ethiopia.

METHOD

A retrospective cohort study was conducted at an institution, involving 583 randomly selected neonates diagnosed with congenital heart disease. In the current study, the dependent variable was survival status. Data entry utilized EpiData data version 4.6, and analysis was performed using STATA version 16. Probability of death was compared using the log-rank test and Kaplan-Meier failure curve. Significant predictors were identified using bivariable and multivariate Cox regression. Model fitness and proportional hazard assumptions were evaluated using the Cox-Snell graph and Global test, respectively. Associations were assessed by adjusted hazard ratios with 95% confidence intervals.

RESULTS

The study participants were followed for 4844 days. The mortality rate was 9.9%. The incidence density was 11.9 per 1000 person-days of observation. Neonatal sepsis (AHR: 2.24; 95% CI [1.18-4.23]), cyanotic congenital heart disease (AHR: 3.49; 95% CI [1.93-6.28]), home delivery (AHR: 1.9; 95% CI [1.06-3.6]), maternal history of gestational diabetes mellitus (AHR: 1.94; 95% CI [1.04-3.61]), and having additional congenital malformations (AHR: 2.49; 95% CI [1.33-4.67]) were significant predictors for neonatal mortality.

CONCLUSION AND RECOMMENDATION

The incidence density of mortality was high compared to studies conducted in developed countries. Neonatal sepsis, type of congenital heart disease, place of delivery, maternal history of gestational diabetes mellitus, and having an additional congenital malformation were significant predictors of mortality among neonates with congenital heart disease. Therefore, healthcare providers should pay special attention to patients with identified predictors. Furthermore, the Federal Ministry of Health, stakeholders, and policymakers should collaborate to address this issue.

Predictive models for sepsis in children with Staphylococcus aureus bloodstream infections: a retrospective cohort study

BACKGROUND

The presence of Staphylococcus aureus in the bloodstream can lead to the development of sepsis; however, the severity and risk factors of the systemic inflammatory response to Staphylococcus aureus bloodstream infections were unclear. This study is aimed to build a model to predict the risk of sepsis in children with Staphylococcus aureus bloodstream infections.

METHODS

A retrospective analysis of hospitalized pediatric patients diagnosed with Staphylococcus aureus bloodstream infections was performed between January 2013 and December 2019. Each patient was assessed using the pediatric version of the Sequential Organ Failure Assessment score (pSOFA) within 24 h of blood culture collection. A nomogram based on logistic regression models was constructed to predict the risk factors for sepsis in children with Staphylococcus aureus bloodstream infections. It was validated using the area under the receiver-operating characteristic curve (AUC).

RESULTS

Of the 94 patients included in the study, 35 cases (37.2%) developed sepsis. The pSOFA scores ranged from 0 to 8, with 35 patients having a pSOFA score of ≥ 2. Six children (6.4%) died within 30 days, who were all from the sepsis group and had different pSOFA scores. The most common organs involved in sepsis in children with staphylococcal bloodstream infections were the neurologic system (68.6%), respiratory system (48.6%), and coagulation system (45.7%). Hospital-acquired infections (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.3-7.2), implanted catheters (aOR, 10.4; 95% CI, 3.8-28.4), procalcitonin level ≥ 1.7 ng/mL (aOR, 15.4; 95% CI, 2.7-87.1), and underlying diseases, especially gastrointestinal malformations (aOR, 14.0; 95% CI, 2.9-66.7) were associated with Staphylococcus aureus sepsis. However, methicillin-resistant Staphylococcus aureus infection was not a risk factor for sepsis. The nomogram had high predictive accuracy for the estimation of sepsis risk, with an AUC of 0.85.

CONCLUSIONS

We developed a predictive model for sepsis in children with Staphylococcus aureus infection.

The Successful Management of Gangrenous Pneumococcal Infection in an Infant With Polysplenia Syndrome

This study describes the successful management of gangrenous pneumococcal infection in an infant with polysplenia, a rare congenital malformation characterized by multiple aberrant nodules of splenic tissue. The patient, a three-month-old girl with congenital heart defects and incomplete vaccination, presented with fever, irritability, and oxygen desaturation, followed by erythematous skin changes. The diagnosis revealed sepsis caused by Streptococcus pneumoniae, accompanied by extensive gangrenous skin lesions and signs of disseminated intravascular coagulation. Polysplenia was incidentally discovered during radiological investigation. Aggressive resuscitation measures and prolonged antibiotic administration led to significant improvement, including regression of skin lesions. This case emphasizes the importance of timely immunization and parental awareness for infants with spleen-related congenital malformations. Screening for undiagnosed malformative defects in congenital heart disease patients can aid in early detection and prevention of life-threatening complications. The successful management demonstrates the critical role of pediatric intensive care units in treating severe systemic infections.

Immunological differences between heart- and kidney-transplanted children: a cross-sectional study

Post-transplantation lymphoproliferative disorder is a potentially mortal complication after heart transplantation in children. As the immune system plays a crucial role in the development of lymphoma, we explored the influence of thymus function in relation to immunosuppressive treatment in organ-transplanted children and healthy control subjects. A prospective case-control study was performed at a single centre, in which 36 children who had undergone heart transplantation were compared to two control groups: 34 kidney-transplanted children and 33 healthy age- and sex-matched children. T- and B-lymphocyte subtypes and monocytes were analysed by flow cytometry, and T-cell receptor excision circles were assessed using quantitative polymerase chain reaction. Heart-transplanted children had a lymphocyte profile characterised by reduced or absent thymic function with low numbers of T-cell receptor excision circles and total and naïve T cells, together with immune activation against the allograft. Despite similar immunosuppressive treatment, the kidney-transplanted group showed an activated T-lymphocyte compartment.

Clinical characteristics and outcomes of carbapenem-resistant Enterobacterales bacteremia in pediatric patients

BACKGROUND/PURPOSE

Clinical data on carbapenem-resistant Enterobacterales (CRE) bacteremia in the pediatric population are limited. This study investigated the clinical characteristics and outcomes of pediatric CRE bacteremia.

METHODS

Clinical data on bacteremia caused by carbapenem-susceptible and carbapenem-resistant Enterobacterales, including Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia marcescens, Proteus mirabilis, Citrobacter spp., and Morganella spp., in pediatric patients from a children's hospital in Taiwan were retrospectively retrieved and analyzed.

RESULTS

From January 2013 to December 2021, 471 clinical isolates of Enterobacterales bacteremia were identified in 451 episodes from 379 pediatric patients. Among all the isolates, the predominant species were E. coli (199/471, 42.2%), Klebsiella spp. (168/471, 35.6%), and Enterobacter spp. (59/471, 12.5%), with carbapenem-resistance rates of 1.5%, 11.9%, and 25.0%, respectively. Overall, 40 (8.4%) showed a carbapenem resistance phenotype. Patients' all-cause mortality rate at 14 days was significantly higher in CRE bacteremia episodes than non-CRE ones (12.5% vs. 3.6%, p < 0.05). The predicting factor of a CRE bacteremia episode was the causative agent of Enterobacter spp. (adjusted OR of 2.551, CI 1.073-6.066, p < 0.05) and ESBL-producing phenotype (adjusted OR 14.268, CI 5.120-39.762, p < 0.001).

CONCLUSION

Bloodstream infections caused by CRE are associated with a higher mortality rate in the pediatric population. Attention must be paid to preventing and managing pediatric patients with CRE infections.

Pediatric Heart Failure Inpatient Mortality: A Cross-Sectional Analysis

Background

Heart failure constitutes significant morbidity and mortality among the pediatric population. Few data exist on the prevalence and mortality rate of pediatric heart failure (pHF) in the United States.

Objectives

This study aimed to determine the in-hospital mortality and the principal diagnoses in pediatric patients with heart failure who died while being hospitalized in the United States.

Methods

This is a retrospective cross-sectional study using data from the 2019 Kid Inpatient Database (KID). The KID contained data on hospitalized children below 21 years of age. Using Stata 17 software (StataCorp LLC, College Station, Texas), the data were searched for heart failure diagnoses using International Classification of Diseases 10th revision Clinical Modification (ICD-10-CM) codes. By using the “rank” command in Stata, the most common principal diagnoses were placed in descending order of frequency, and these were further divided into different ICD-10 code categories.

Results

There were 16,206 pHF admissions in 2019. Of these admissions, 1,023 (6.31%) patients died. The top five principal ICD 10 code categories among all pHF deaths in descending order were circulatory system (17.95%), congenital/chromosomal abnormalities (17.43%), respiratory system (10.28%), infectious diseases (9.24%, and perinatal diseases (7.90%). Among all pHF deaths, sepsis of unspecified organisms (5.14%), hypoplastic left heart syndrome (HLHS) (3.19%), and acute respiratory failure with hypoxia (3.14%) were the most common primary diagnoses.

Conclusion and significance

Pediatric heart failure in-hospital overall mortality is 6.31%, and sepsis of unspecified organisms, HLHS, and acute respiratory failure are the most common principal diagnoses among these children. Preventive measures and prompt treatment of infections are paramount to reducing pHF mortality.

Bacterial Sepsis among Children with Congenital Heart Disease in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Bacterial Sepsis is a serious medical problem affecting children with Congenital Heart Disease (CHD). The pattern and factors predicting outcome of bacterial sepsis have not been studied in Africa. The study aimed to describe the pattern and outcome of bacterial sepsis among children with CHD in Tikur Anbessa Specialized Hospital (TASH).

METHODS

A cross-sectional study was carried out among children with CHD and sepsis at TASH between May 2017 and July 2020. Structured questionnaires were used for data collection. Statistical significance was set at P value < 0.05, and multivariable logistic regression was used to determine predictors.

RESULTS

This study included 384 CHD children with sepsis. Proportion of culture proven bacterial sepsis was 17.1 % (66) (95% CI: 13.6-21.3). Coagulase negative staphylococcus aureus 7% (27), Staphylococcus aureus 4.4% (17) and Actinobacteria 1.8% (7) were the common isolated bacteriological agents. Death was documented in 25% (96) of study subjects. Down syndrome subjects were 2.4 times [aOR=2.416 (95%CI: 1.367-4.264)] more likely to die from sepsis. Those with associated comorbidities (Apert syndrome, Cerebral palsy, Chiari 2 malformation, Patau syndrome, Noonan syndrome, Congenital Rubella, Portal vein thrombosis, HIV, Scoliosis and VACTERL association) were 4.4 times more likely to die from sepsis [aOR=4.418 (95%CI: 1.617-12.072)].

CONCLUSION

Bacterial sepsis is a common problem among children with CHD. Gram positive bacteria were common causes. Down syndrome and other co morbidities predicted bacterial sepsis mortality. Blood culture and sensitivity tests are recommended to halt the high mortality seen in Down syndrome or those with co morbidities.

A Cluster of Neonatal Infections Caused by Candida auris at a Large Referral Center in Colombia

BACKGROUND

Globally, Candida auris is an emerging pathogen that poses an essential threat in healthcare settings presenting as outbreaks requiring significant allocation of infection control interventions to curb transmission. This fungal pathogen was initially identified in 2009 in Japan, but it has spread to all continents. Candida auris poses significant diagnostic and treatment challenges. Conventional microbiology laboratories often misidentify this pathogen as Candida haemulonii or as other Candida spp., Rhodoturola glutinis, and even with some bacterial pathogens, including Neisseria meningitidis serogroup A. Furthermore, C. auris displays distinct mechanisms of antifungal resistance to azoles and amphotericin B formulations. Most of the case series and outbreak reports have included invasive infections in adult populations.

METHODS

Herein, we present a cluster of neonatal infections caused by Candida auris at a large referral center in Colombia.

RESULTS

We report a case series of 8 neonates and infant patients who were seen at a large referral center in Colombia and who develop invasive infections caused by C. haemulonii and C. auris.

DISCUSSION

Our report highlights the diagnostic challenges in identifying this fungal pathogen correctly, its clinical spectrum of disease, recommendations for empiric antifungal therapy, and it is not always associated with a high case fatality rate.

Causes of neonatal and postneonatal death among infants with birth defects in Texas

BACKGROUND

The proportion of deaths attributed to various causes has not been quantified among infants with birth defects. We sought to describe the causes of neonatal and postneonatal death among infants in the Texas Birth Defects Registry.

METHODS

We calculated frequencies and percentages for both underlying causes and all causes (underlying or contributing) of neonatal (0-27 days) and postneonatal (28-364 days) death listed on death certificates among infants born alive with birth defects and delivered in Texas during 1999-2013 (n = 8,389 deaths). Analyses were repeated separately for infants with isolated, multiple, and syndromic defects.

RESULTS

After birth defects, the most frequently listed causes of neonatal death were preterm/low birth weight (10%), circulatory system diseases (8%), and sepsis (5%). The leading postneonatal causes of death beyond birth defects were circulatory system diseases (32%), sepsis (11%), and renal failure (7%).

CONCLUSIONS

Improved understanding of the causes of mortality among infants with birth defects may help identify priorities for postnatal care. Our results suggest that potentially modifiable causes of death (e.g., circulatory system diseases, sepsis) contribute substantially to mortality in this population. Prioritizing continued improvements in prevention, diagnosis, and management of preventable conditions may reduce mortality among infants born with birth defects.

Nosocomial Severe Bacterial Infection After Cardiac Surgery for Complex Congenital Heart Disease in Heterotaxy Syndrome

BACKGROUND

Patients with heterotaxy syndrome (HS), commonly associated with hyposplenism and complex congenital heart disease (CCHD), require multiple-stage single ventricle type operation for long-term survival. Although a higher risk of community-acquired sepsis and mortality rate was reported in CCHD with HS compared with those without HS, whether the risk of postoperative severe bacterial infection (SBI) is higher in patients with HS remains unknown.

METHOD

All patients with CCHD (with and without HS) born between 2001 and 2013 who received cardiac surgery between 2001 and 2018 were enrolled. We analyzed the epidemiology and risk of postoperative SBI in this CCHD cohort.

RESULT

In total, 101 patients of CCHD with HS and 164 patients without HS were enrolled. The mean postoperative nosocomial SBI rate was 0.73/100 patient-days in patients with HS and 0.56/100 patient-days in patients without HS (P = 0.13). Multivariate Cox regression analysis demonstrated that the most critical risk factor for postoperative SBI was postoperative intubation >14 days. Preoperative risk factors, including a nonstandard surgical procedure and multiple surgeries, but not HS, were associated with an increased risk of postoperative nosocomial SBI. The pathogens of infection were also similar between these 2 groups.

CONCLUSION

Although commonly associated with hyposplenism, patients with HS have similar postoperative SBI risk and pathogens as those with CCHD alone.

Invasive candidiasis: Risk factor for mortality in a pediatric tertiary care hospital in south of Brazil

BACKGROUND

Invasive candidiasis (IC) is a major cause of morbimortality in children. Previous studies described the clinical characteristics and risk factors for this infection; however, limited data are available on the predictors of mortality in these patients. In this context, we evaluated the risk factors associated with death due to IC in a pediatric tertiary care hospital in South of Brazil.

METHODS

This is a retrospective, cross-sectional, observational, and analytical study of a series of pediatric patients with clinical and laboratory diagnosis of IC from March 2014 to September 2017. Univariate and multivariate analysis were performed to estimate the association between the characteristics of the patients and death.

RESULTS

A total of 94 cases of IC were included. The incidence was 1.13 cases per 1000 patients/d, with a mortality rate of 14%. There was a predominance of non-albicans Candida (71.3%) in IC cases and, although there is no species difference in mortality rates, biofilm formation was associated with increased mortality. Clinical characteristics such as male sex, stay in the intensive care unit, and thrombocytopenia; comorbidities such as cardiological disease and renal insufficiency; and risks such as mechanical ventilation and dialysis were associated with increased mortality.

CONCLUSION

Data from this study suggest that biofilm formation by Candida sp. is associated with increased mortality, and this is the first study to correlate the male sex and cardiological disease as risk factors for death in pediatric IC patients.

Children with Chronic Disease Bear the Highest Burden of Pediatric Sepsis

OBJECTIVE

To describe the contemporary epidemiology of pediatric sepsis in children with chronic disease, and the contribution of chronic diseases to mortality. We examined the incidence and hospital mortality of pediatric sepsis in a nationally representative sample and described the contribution of chronic diseases to hospital mortality.

STUDY DESIGN

We analyzed the 2013 Nationwide Readmissions Database using a retrospective cohort design. We included non-neonatal patients <19 years of age hospitalized with sepsis. We examined patient characteristics, the distribution of chronic disease, and the estimated national incidence, and described hospital mortality. We used mixed effects logistic regression to explore the association between chronic diseases and hospital mortality.

RESULTS

A total of 16 387 admissions, representing 14 243 unique patients, were for sepsis. The national incidence was 0.72 cases per 1000 per year (54 060 cases annually). Most (68.6%) had a chronic disease. The in-hospital mortality was 3.7% overall-0.7% for previously healthy patients and 5.1% for patients with chronic disease. In multivariable analysis, oncologic, hematologic, metabolic, neurologic, cardiac and renal disease, and solid organ transplantation were associated with increased in-hospital mortality.

CONCLUSIONS

More than 2 of 3 children admitted with sepsis have ≥1 chronic disease and these patients have a higher in-hospital mortality than previously healthy patients. The burden of sepsis in hospitalized children is greatest in pediatric patients with chronic disease.

Perioperative infections in congenital heart disease

BACKGROUND

Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality.

METHODS

A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed.

RESULTS

Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition.

CONCLUSIONS

The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.

Survival, by Birth Weight and Gestational Age, in Individuals With Congenital Heart Disease: A Population-Based Study

BACKGROUND

Congenital heart disease (CHD) survival estimates are important to understand prognosis and evaluate health and social care needs. Few studies have reported CHD survival estimates according to maternal and fetal characteristics. This study aimed to identify predictors of CHD survival and report conditional survival estimates.

METHODS AND RESULTS

Cases of CHD (n=5070) born during 1985-2003 and notified to the Northern Congenital Abnormality Survey (NorCAS) were matched to national mortality information in 2008. Royston-Parmar regression was performed to identify predictors of survival. Five-year survival estimates conditional on gestational age at delivery, birth weight, and year of birth were produced for isolated CHD (ie, CHD without extracardiac anomalies). Year of birth, gestational age, birth weight, and extracardiac anomalies were independently associated with mortality (all P≤0.001). Five-year survival for children born at term (37-41 weeks) in 2003 with average birth weight (within 1 SD of the mean) was 96.3% (95% CI, 95.6-97.0). Survival was most optimistic for high-birth-weight children (>1 SD from the mean) born post-term (≥42 weeks; 97.9%; 95% CI, 96.8-99.1%) and least optimistic for very preterm (<32 weeks) low-birth-weight (<1 SD from mean) children (78.8%; 95% CI, 72.8-99.1).

CONCLUSIONS

Five-year CHD survival is highly influenced by gestational age and birth weight. For prenatal counseling, conditional survival estimates provide best- and worst-case scenarios, depending on final gestational age and birth weight. For postnatal diagnoses, they can provide parents with more-accurate predictions based on their baby's birth weight and gestational age.

Congenital heart defects in newborns with apparently isolated single gastrointestinal malformation: A retrospective study

BACKGROUND

Congenital gastrointestinal system malformations/abdominal wall defects (GISM) may appear as isolated defects (single or complex), or in association with multiple malformations. The high incidence of association of GISM and congenital heart defects (CHD) in patients with syndromes and malformative sequences is known, but less expected is the association of apparently isolated single GISM and CHD. The aim of this study was to investigate the frequency of CHD in newborns with isolated GISM, and the possibility to modify the diagnostic-therapeutic approach just before the onset of cardiac symptoms or complications.

METHODS

Anamnestic, clinical, and imaging data of newborns requiring abdominal surgery for GISM, between 2009 and 2014, were compared with a control group of healthy newborns. Distribution of GISM and cardiovascular abnormalities were analyzed, and risk factors for adverse outcomes were identified.

RESULTS

Seventy-one newborns with isolated GISM were included in this study. More frequent GISM were intestinal rotation and fixation disorders. CHD were observed in 15.5% of patients, augmenting their risk for morbidity. Risk factors for morbidity related to sepsis were identified in central venous catheter, intestinal stoma, and H2-inhibitor-drugs. Moreover, 28.2% of newborns presented only functional cardiac disorders but an unexpectedly higher mortality.

CONCLUSIONS

The high incidence of congenital heart disease in infants with apparently isolated GISM confirms the need to perform an echocardiographic study before surgery to improve perioperative management and prevent complications such as sepsis and endocarditis.

Clonal Structure and Characterization of Staphylococcus aureus Strains from Invasive Infections in Paediatric Patients from South Poland: Association between Age, spa Types, Clonal Complexes, and Genetic Markers

The aim of current study was to examine clonal structure and genetic profile of invasive Staphylococcus aureus isolates recovered from infants and children treated at the Jagiellonian University Children’s Hospital of Krakow, Poland. The 107 invasive S. aureus isolates, collected between February 2012 and August 2014, were analysed retrospectively. Antimicrobial susceptibility testing, spa typing and DNA microarray analysis were performed to determine clonal distribution, diversity and gene content in regard to patients characteristics. In total, 107 isolates were recovered from 88 patients with clinical symptoms of invasive bacterial infection. The final set of 92 non-duplicate samples included 38 MRSA isolates. Additionally, a set of 54 S. aureus isolates collected during epidemiological screening was genotyped and analysed. There were 72 healthcare-associated (HCA) and 20 community-onset (CO) infection events caused by 33 and 5 MRSA isolates, respectively. The majority of isolates were affiliated with the major European clonal complexes CC5 (t003, spa-CC 002), CC45 (spa-CC 015), CC7 or CC15 (t084, t091, spa-CC 084). Two epidemic clones (CC5-MRSA-II or CC45-MRSA-IV) dominated among MRSA isolates, while MSSA population contained 15 different CCs. The epidemiological screening isolates belonged to similar genetic lineages as those collected from invasive infection cases. The HCA infection events, spa types t003, t2642 or CC5 were significantly associated with infections occurring in neonates and children under 5 years of age. Moreover, carriage of several genetic markers, including erm(A), sea (N315), egc-cluster, chp was significantly higher in isolates obtained from children in this age group. The spa types t091 and t008 were underrepresented among patients aged 5 years or younger, whereas spa type t008, CC8 and presence of splE was associated with infection in children aged 10 years or older. The HCA-MRSA strains were most frequently found in children under 5 years, although the majority of invasive infections was associated with MSSA strains. Moreover, an association between age group of children from the study population and a specific strain genotype (spa type, clonal complex or genetic content) was observed among the patients.

Management of the Preterm Infant with Congenital Heart Disease

The premature neonate with congenital heart disease (CHD) represents a challenging population for clinicians and researchers. The interaction between prematurity and CHD is poorly understood; epidemiologic study suggests that premature newborns are more likely to have CHD and that fetuses with CHD are more likely to be born premature. Understanding the key physiologic features of this special patient population is paramount. Clinicians have debated optimal timing for referral for cardiac surgery, and management in the postoperative period has rapidly advanced. This article summarizes the key concepts and literature in the care of the premature neonate with CHD.

No survival benefit with empirical vancomycin therapy for coagulase-negative staphylococcal bloodstream infections in infants

BACKGROUND

Coagulase-negative Staphylococcus (CoNS) is the most common cause of bloodstream infections (BSI) in hospitalized infants. CoNS BSI is most reliably treated with vancomycin; however, concerns about side effects and promoting resistance often delay empirical vancomycin therapy until culture results become available.

METHODS

All infants with CoNS BSI discharged from 348 neonatal intensive care units managed by the Pediatrix Medical Group from 1997 to 2012 were identified. Empirical vancomycin therapy was defined as vancomycin exposure on the day of the first positive blood culture. Delayed vancomycin therapy was defined as vancomycin exposure 1-3 days after the first positive blood culture. We used multivariable logistic regression with random effects for site to evaluate the association between the use of empirical vancomycin therapy versus delayed vancomycin therapy and 30-day mortality, controlling for gestational age, small-for-gestational age status, postnatal age on the day of the first positive culture, oxygen requirement, ventilator support and inotropic support on the day the first positive culture was obtained.

RESULTS

A total of 4364 infants with CoNS BSI were identified; 2848 (65%) were treated with empirical vancomycin. The median postnatal age at first positive culture was 14 days (interquartile range: 9, 21). Unadjusted 30-day mortality was similar for infants treated with empirical vancomycin and infants treated with delayed vancomycin therapy [166/2848 (6%) vs. 69/1516 (4%); P = 0.08]. There was no significant difference in 30-day mortality on multivariable analysis [odds ratio: 1.14 (0.84, 1.56)]. The median duration of bacteremia was 1 day longer for infants with delayed vancomycin therapy [4 days (interquartile range: 2, 6) vs. 3 days (2, 5); P < 0.0001].

CONCLUSIONS

The median duration of bacteremia was 1 day longer in infants with CoNS BSI who received delayed vancomycin therapy. Despite this finding, empirical vancomycin therapy for CoNS BSI was not associated with improved mortality.

Neonatal sepsis and multiple skin abscess in a newborn with Down's syndrome: A case report

Neonatal sepsis is a leading cause of neonatal mortality. Congenital heart disease accounts for additional risk of sepsis in neonates. Here we report a case of Down's syndrome with late onset neonatal sepsis associated with multiple superficial skin abscesses simulating staphylococcal infection. The baby was empirically treated with vancomycin. Subsequently, multidrug resistant Klebsiella pneumoniae was detected from both pus and blood culture. Change to appropriate antibiotic resulted in clinical recovery. Although sepsis is one of the major ailments in neonates, atypical presentations of neonatal sepsis in Down's syndrome patients are underreported. Here we highlight the atypical presentation of Klebsiella sepsis and the importance of early antibiogram in such cases.