Surveillance on meticillin-sensitive Staphylococcus aureus colonization and infection in a neonatal intensive care unit

BACKGROUND

Meticillin-sensitive Staphylococcus aureus (MSSA) infection is a significant health concern in neonatal intensive care units (NICUs). Bacterial colonization increases the risk of subsequent infection, leading to morbidity and mortality.

AIM

To report the findings of a retrospective cohort study on the surveillance of MSSA colonization and infection in NICU patients.

METHODS

The weekly microbial surveillance results for MSSA colonization in the throat, nose, anus, and groin, as well as invasive and non-invasive MSSA infections, were analysed from November 2020 to June 2022. The MSSA infection and colonization risk were compared after adjustment for confounders by stepwise logistic regression analysis.

FINDINGS

Three hundred and eighty-three neonates were screened; 42.8% (N=164) were MSSA colonized. Significant risk factors for MSSA colonization were length of stay, vaginal delivery and extreme low gestational age <28 weeks (ELGAN) (all P<0.05). The surveillance detected 38 (9.9%) mild MSSA infections and 11 (2.9%) invasive MSSA infections. Neonatal colonization with MSSA is a major risk factor for MSSA infection overall (29.3% in colonized/infected vs 70.7% colonized/not-infected and 0.5% in not-colonized/infected vs 99.5% in not-colonized/not-infected infants) and invasive MSSA infections (6.1% in colonized/infected vs 93.9% in colonized/not-infected and 0.5% in non-colonized/infected vs 99.5% not-colonized/not-infected infants). Also, extreme low birth weight (<1000 g), ELGAN and invasive ventilation were significant risk factors for MSSA infections (all, P<0.05).

CONCLUSIONS

The link between postnatal MSSA colonization and subsequent MSSA infection offers possibilities for prevention. Additional research is needed to explore the association between vaginal birth and the pathogenesis of neonatal MSSA colonization.

Neurodevelopmental outcome in children with congenital cytomegalovirus infection: A prospective multicenter cohort study

BACKGROUND

Congenital cytomegalovirus infection (cCMV) is the most common congenital infection worldwide and is a major cause of neurodevelopmental impairment in children. At this point there are insufficient data on neurodevelopmental outcome of children with cCMV, both symptomatic and asymptomatic.

AIM

This study aimed to describe the neurodevelopmental outcome in a large prospective cohort of children with cCMV.

METHODS

All children with cCMV, included in the Flemish cCMV register, were eligible for this study. Data on neurodevelopmental outcome was available in 753 children. Data on neuromotor, cognitive, behavioral, audiological and ophthalmological outcome were analyzed.

RESULTS

Neurodevelopmental outcome was normal in 530/753 (70,4 %) at any age of last follow-up. Mild, moderate and severe neurodevelopmental impairment was found in 128/753 (16,9 %), 56/753 (7,4 %) and 39/753 (5,2 %), respectively. Adverse outcome is found both in the symptomatic and asymptomatic children (53,5 % versus 17,8 %). Autism spectrum disorder (ASD) was diagnosed more often than in the general population in Flanders (2,5 % versus 0,7 %). Speech and language impairment was found in 2 %, even in absence of hearing loss.

CONCLUSION

Both symptomatic and asymptomatic cCMV children are at risk of sequelae, with higher risk in case of first trimester infection. During follow-up of this population, special attention should be given to the audiological follow-up, the presence of hypotonia at young age, the possible higher risk of ASD and the risk of speech and language impairment even in absence of hearing loss. Our results emphasize the need for multidisciplinary neurodevelopmental follow-up of all cCMV infected children.

Non-primary CMV infection not always innocent. A case-report and literature review

OBJECTIVES

Cytomegalovirus (CMV) is the most common infectious cause of congenital malformations. CMV infections are frequently symptomatic in case of a primary infection during pregnancy. Generally, maternal immunity protects the newborn against a symptomatic course of the CMV infection.

METHODS

We present clinical information and medical images of a neonate with non-primary congenital CMV infection.

RESULTS

We report the case of a severe congenital infection in a newborn clinically presenting with diffuse petechia, facial dysmorphisms, respiratory distress, hepatomegaly and hypotonia. The girl was born to a mother with CMV immunity. Blood results demonstrated thrombocytopenia and elevated transaminases. Brain MRI revealed ventricular dilatation and germinolytic cysts, compatible with CMV infection. Auditory brain stem response testing was abnormal. CMV culture of saliva was positive. This led to the diagnosis of a severe congenital CMV infection due to a non-primary maternal infection. Antiviral treatment with valganciclovir was initiated immediately and continued for 6 months.

CONCLUSION

Our case illustrates that, even when the mother was demonstrated CMV immune, congenital CMV infection is still an important differential diagnostic consideration in neonates presenting with congenital cerebral abnormalities, thrombocytopenia and/or hearing loss.

ABBREVIATIONS

ABR: auditory brainstem responses; CMV: Cytomegalovirus; CPAP: Continuous Positive Airway Pressure; CRP: C-Reactive Protein; dBnHL: Decibel Above Normal Adult Hearing Level; IV: intravenously; MRI: Magnetic Resonance Imaging; SGA: Small for Gestational Age; SNHL: Sensorineural Hearing Loss.

[A series of 20 cases of endogenous endophthalmitis]

BACKGROUND

The purpose of this case series was to evaluate both the visual and systemic prognosis of patients with endogenous endophthalmitis.

MATERIAL AND METHODS

We reported a series of 20 cases of endogenous endophthalmitis occurring between 2012 and 2015 at the university medical center in Toulouse.

RESULTS

The mean age was 67 (±43.3) years with a male predominance (n=11). The site of entry was found in 14 cases (87.5%). In 11 cases (69%), the causative agent was a bacterium; a fungal infection was found in five cases. Visual acuity after maximal medical and surgical treatment was limited to "no light perception" in 7 cases (35%), "hand motion" in 2 cases (10%), "finger counting" in 3 cases (15%) and 10/10 in 2 cases (10%). One case had no final data. The main site of entry was found to be associated endocarditis (n=7), central venous line or venipuncture (n=6). The main local complications were retinal detachment (n=6), cataract (n=5) and choroidal neovascularization secondary to scarring (n=2).

CONCLUSIONS

Endogenous endophthalmitis is associated with poor visual prognosis. It is also often associated with systemic complications that may be life-threatening.

Persistence of foveal capillary plexi in a case of fovea plana evident on OCT angiography

We report the case of a 12-year-old boy with fovea plana discovered on a systematic work-up. His best-corrected visual acuity was limited to 20/25 in both eyes. Anterior segment examination showed no evidence of iris transillumination or aniridia. Macular OCT revealed persistence of the inner nuclear layers in the foveolar area and an absence of foveal pits, suggesting a diagnosis of fovea plana. Fluorescein angiography revealed that the foveal avascular zone (FAZ) was absent. OCT angiography revealed persistence of the superficial and deep capillary plexi. Our case confirms that OCT angiography affords additional insights into macular exploration and the diagnosis of fovea plana by revealing absence of the foveal pit associated with persistence of both superficial and deep capillary plexi in the foveal area.

[What were the obstacles to the development of outpatient cataract surgery in Toulouse University Hospital in 2013?]

INTRODUCTION

Cataract surgery is an ideal candidate for outpatient care. In 2013, in the Toulouse University Hospital, outpatient care rate for phacoemulsification was 75.8%. We conducted this study to identify the barriers that limit the development of outpatient cataract surgery in our establishment.

MATERIAL AND METHODS

A retrospective observational study was conducted. We included all patients who underwent phacoemulsification (Medical Act Code BFGA004) as a traditional inpatient in 2013. We excluded admissions for which the medical, anesthesia or nursing records, as well as scheduling sheets, were incomplete. Patients were classified according to the reason for inpatient hospitalization and the type of surgery: cataract as primary surgery or cataract as combined procedure.

RESULTS

Two hundred and ninety-eight stays were included with a mean age of 66.8 ± 16.8 years, and a male/female ratio of 0.76. The indication for inpatient hospitalization was a social, surgical or anesthetic reason in the following respective proportions: 41, 34 and 8% of cases. Failure of ambulatory care represented 7% of cases. Social isolation represented 89% of social reasons. In a combined gesture, the reason was surgical in 89% of cases.

CONCLUSION

Development of outpatient surgery requires the participation of all involved. Taking into account the social factors is an essential element for developing ambulatory surgery. Social isolation is a frequent situation requiring a societal response. With regard to surgical considerations, practice patterns must target outpatient combined procedures in particular.

[Multimodal imaging in the diagnosis of acute macular neuroretinopathy]

INTRODUCTION

Acute macular neuroretinopathy is a retinal disease, usually presenting with a "normal fundus". Thus, this condition can be mistaken for optic neuropathy. Herein we present five clinical cases of patients affected with acute macular neuroretinopathy; one of them is a retrospective diagnosis while the others were diagnosed on initial examination. In the five cases, multimodal imaging with infrared photography and OCT helped to establish the diagnosis.

MATERIAL AND METHODS

Retrospective study of five clinical cases. Initial and final best visual acuities as well as infrared and OCT imaging were collected for all patients.

RESULTS

All patients initially reported a visual disturbance associated with a more or less severe decrease in visual acuity. Infrared imaging showed a dark, perifoveolar appearance of the lesions. In all cases, OCT images showed thickening and hyperreflectivity of the outer plexiform layer, extending towards the outer retinal layers.

CONCLUSION

Acute macular neuroretinopathy is a clinical entity that has been long-described, which now benefits widely from new imaging technologies, allowing an earlier and more accurate diagnosis, but calling into question the actual name of this condition. The exact pathophysiology of the condition remains nonetheless incompletely elucidated.

Management of the neonate at risk for early-onset Group B streptococcal disease (GBS EOD): new paediatric guidelines in Belgium

Despite group B streptococcal (GBS) screening in late pregnancy and intrapartum antimicrobial prophylaxis, early-onset sepsis in neonates remains a common source of neonatal morbidity and mortality especially in preterm neonates. The identification of neonates with early-onset sepsis is usually based on perinatal risk factors. Clinical signs are aspecific and laboratory tests are not sensitive. Therefore, many clinicians will overtreat at-risk infants. Inappropriate treatment with antibiotics increases the risk for late-onset sepsis, necrotizing enterocolitis, mortality, and prolongs hospitalisation and costs. In 2003, the Belgian Health Council published guidelines for the prevention of perinatal GBS infections. This report presents the Belgian paediatric management guidelines, which have been endorsed by the Belgian and Flemish societies of neonatology and paediatrics. The most imported changes in the 2014 guidelines are the following: recommendations for a lumbar puncture; clarification of normal spinal fluid parameters and blood neutrophil indices corrected for gestation age; specific timing for diagnostic testing after birth; no indication for diagnostic testing in asymptomatic newborns unless additional risk factors; a revised algorithm for management of neonates according to maternal and neonatal risk factors; and premature infants described as those below 35 weeks instead of 37 weeks. The guidelines were made on the basis of the best evidence and on expert opinion when inadequate evidence exists.

[Recurrent bilateral anterior uveitis due to Leishmania infantum in a patient with immune deficiency related to HIV infection: a case report and literature review]

We report the case of a 56-year-old patient, presenting with bilateral hypertensive anterior uveitis due to Leishmania infantum, in the setting of immune deficiency related to HIV infection. The etiology of the uveitis was diagnosed following detection of L. infantum DNA on anterior chamber paracentesis. Initially, the patient received an intravitreal injection of liposomal amphotericin B, systemic antiparasitic treatment, topical steroid and ocular hypotensive treatment. Due to unfavourable disease progression in the right eye, we re-evaluated the anti-inflammatory, antiretroviral and antiparasitic medications (beginning meglumine antimoniate): the uveitis in the left eye was thus able to be controlled. We followed the efficacy of treatment with weekly quantification of Leishmania DNA in the aqueous humor. Uveitis secondary to leishmaniasis is rare and serious. Physicians must be aware of this cause of uveitis, particularly in immunodeficient patients. The quantitation of Leishmania DNA in the aqueous humor is an indispensible tool for monitoring the disease.

Epidemiology of pertussis in children of Flanders Belgium: can healthcare professionals be involved in the infection?

Pertussis is a communicable disease whose registration incidence in the Flemish region of Belgium has increased since 2003. Originally, this increment was obvious only in the province of Antwerp, but since 2012, there has also been an increase in the registered cases of pertussis in other Flemish provinces. The overall registration incidence for pertussis in Flanders was 5·6 per 100 000 in 2012. The majority of these cases were identified among young children, but older children and adults were also affected. Increased awareness, new diagnostic tools, better registration, waning immunity, and circulation of new strains were most likely associated with the increase in reporting. Although many of the pertussis infections we studied occurred within family units, several healthcare workers who had been in contact with young children were also identified as sources of pertussis. A number of these were index cases, while others were secondary infections. Finally, a fatal neonatal pertussis case is presented to illustrate the severity of the disease in young unvaccinated children.

[Sutureless transconjunctival 20-gauge vitrectomy]

PURPOSE

To evaluate the safety and efficacy of 20-gauge transconjunctival sutureless vitrectomy for a variety of vitreoretinal conditions.

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 29 eyes of 29 patients treated with 20-gauge transconjunctival sutureless vitrectomy. The main outcome measures included intraocular pressure, visual acuity, surgical time, and intraoperative and postoperative complications.

RESULTS

The mean follow-up duration was 5.7 months. There were only two cases of postoperative ocular hypotony (6.9%) and one suspect case of endophthalmitis. Mean overall acuity improved from 0.495 logMar at baseline to 0.29 logMar (p=0.002) and mean total operative time was 19 min. We observed no cases of retinal detachment.

CONCLUSION

Twenty-gauge transconjunctival sutureless vitrectomy is an effective surgical technique, but other studies are needed to confirm its safety and its value in other indications.

[Pars plana vitrectomy, subretinal injection of recombinant tissue plasminogen activator and fluid-gas exchange in the management of massive submacular hemorrhages secondary to age-related macular degeneration]

INTRODUCTION

The natural prognosis of eyes with subretinal hemorrhage resulting from age-related macular degeneration is generally poor. A variety of therapeutic approaches have been developed but no consensus was found. Therefore, we evaluated a technique consisting of pars plana vitrectomy and subretinal rt-PA injection followed by evacuation of the liquid blood using sulfur hexafluoride (SF6).

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 18 eyes of 16 patients with age-related macular degeneration and thick submacular hemorrhage treated with vitrectomy, subretinal injection of rt-PA (0.5mg), and fluid-gas exchange.

RESULTS

The subretinal hemorrhage was displaced in all 18 cases, revealing a choroidal lesion in 17 eyes. A treatable lesion accountable for the bleeding was identified in ten eyes, which all received a secondary treatment (intravitreal injection or photodynamic therapy). After a mean follow-up of 6 months, the final visual acuity improved in ten eyes. Complications consisted of one case of retinal detachment and one case of hyphema.

CONCLUSION

This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. However, further controlled and multicentric studies will be required to assess its efficacy and safety in the management of this difficult clinical problem.

Particularités du traitement chirurgical du décollement de rétine du myope fort de plus de 10 dioptries et son risque hémorragique

INTRODUCTION

We report a series of 79 eyes undergoing primary surgery for rhegmatogenous retinal detachment associated with severe myopia greater than 10 diopters. Specific surgical procedures are recommended for these patients in order to minimize the high incidence of postoperative hemorrhagic complications.

MATERIALS AND METHODS

Seventy-nine eyes of 76 patients treated for retinal detachment with severe myopia greater than 10 diopters were reviewed. Scleral buckling was performed in 21 eyes and pars plana vitrectomy in 58 eyes.

RESULTS

After a mean follow-up period of 23.8 months, the final anatomical success rate was 93.7% (74 cases). Postoperative hemorrhagic complications (suprachoroidal hemorrhage and vitreous hemorrhage) occurred in four cases after scleral buckling and in ten cases after vitrectomy.

DISCUSSION

In this study, primary scleral buckling for retinal detachment was less frequently performed than vitrectomy. Broad scleral buckling may not be associated with higher postoperative hemorrhagic complications, when the buckle does not extend over six clock hours. Postoperative hemorrhagic complications also occurred after vitrectomy; however, scleral buckling associated with vitrectomy does not seem to increase the complication rate.

CONCLUSION

This retrospective study of 79 cases of rhegmatogenous retinal detachment with severe myopia higher than 10 diopters suggests that vitrectomy is often considered a primary procedure. Broad scleral buckling associated with vitrectomy is a safe and effective procedure, with an acceptable incidence of complications when not extending over six clock hours.

[Surgical treatment of inferior retinal detachment: advantages of postoperative traction of the right inferior muscle]

AIM

To evaluate the advantages of keeping the right inferior muscle in traction during external surgery for inferior retinal detachment.

PATIENTS AND METHODS

This was a prospective study involving ten patients consecutively operated on for rhegmatogenous retinal detachment at the Toulouse-Rangueil Teaching Hospital. Internal plugging by air or a C2F6-air mixture was systematically performed, together with external indentation and total subretinal fluid puncture. At the end of surgery, a 2.0 silk thread was set beneath the right inferior muscle and kept in traction from the forehead for a few days. The patient was maintained feet up, in a dorsal decubitus posture.

RESULTS

Results proved excellent, with ten anatomical successes. However, one patient had to have gas reinjected and in another subretinal fluid persisted for 3 months.

DISCUSSION

The risk of surgical failure in inferior retinal detachment is greater because dabbing is more difficult to perform. To make this dabbing easier, we propose maintaining the ocular globe rearward by maintaining traction on the right inferior muscle, which produced excellent results.

CONCLUSION

The technique proposed is easy to perform, and combined with internal dabbing and adequate patient positioning, it should help improve the surgical outcome of inferior retinal detachments.

Intérêt de la torche à plasma en biologie clinique. Quelles applications en toxicologie ?

The multi-elementary quantitation method using inductively coupled plasma mass spectrometry has been widely developed for use with biological fluids. Many elements can be quantified simultaneously in biological fluids, including: Li, Be, B, Al, Mn, Co, Ni, Cu, Zn, Ga, Ge, As, Se, Rb, Sr, Mo, Pd, Cd, Sn, Sb, Te, Ba, W, Pt, Hg, Tl, Pb, Bi, U. The validation procedure is described by the French Society of Clinical Biology. Results for urine are corrected after creatinine determination. We report applications in clinical toxicology and forensic toxicology. Advances in inductively coupled plasma mass spectrometry in the field of clinical biology are particularly important for toxicological analysis. This powerful tool is helpful for better patient care and for the search for cause of death.

Towards a Belgian consensus for prevention of perinatal group B streptococcal disease

BACKGROUND & OBJECTIVES

In Belgium, as in many other countries, group B Streptococcus (GBS) is still the leading cause of sepsis and meningitis in neonates. In 2001, though no Belgian guidelines for their prevention were available, in some hospitals, obstetrical programmes included a GBS prevention policy. With an aim to reach a Belgian consensus for the prevention of perinatal group B streptococcal disease, a national consensum meeting was organized in 2001. We report here our experience and findings of this meeting.

METHODS

In November 2001, obstetricians, neonatologists, microbiologists and infectious diseases specialists were invited to participate in a GBS symposium. International and Belgian speakers presented epidemiological aspects, argued comparative cost-effectiveness of different approaches for prevention and debated technical and practical problems. Management of neonates with risk factors for GBS disease and progress in GBS vaccines were also included in the programme. Further results about Belgian obstetricians' practice and compliance to a policy for prevention of neonatal GBS diseases, as answered in two mail surveys, were commented and discussed. In an interactive session at the end, each participant was asked to vote on the key points related to the different steps of the ideal prevention strategy to recommend.

RESULTS

For the main questions, 94 per cent of participants choose a screening-based approach and 94 per cent shifted from the current use of ampicillin to penicillin as first choice for antimicrobial prophylaxis. Further, 79 per cent voted for an approach with integrated neonatal prophylaxis for selected neonates at high risk for GBS disease and 47 per cent voted for a strategy based on an intrapartum rapid screening-based approach.

INTERPRETATION & CONCLUSION

The state of the question by different speakers, the data from Belgian epidemiology, and the debate about cost-effectiveness of different approaches led to a massive vote in favour of the universal screening-based approach. Based on these results, a working group has been appointed by the Ministry of Health to draft and edit Belgian recommendations for the prevention of perinatal GBS disease.

Twin versus singleton pregnancy and preterm prelabour rupture of the membranes

PURPOSE

The primary purpose of this study was to compare the latency period between preterm prelabour rupture of the membranes (PPROM) and delivery in twin versus singleton pregnancies. The secondary purpose was to compare the neonatal outcome of these two groups.

METHODS

A retrospective case control study was performed on 33 consecutive bichorionic twin pregnancies with gestational age 20 to 36 weeks admitted to the Antwerp University Hospital with PPROM from 1995 to 2000. These were matched with singletons experiencing PPROM at the same gestational age. Groups were compared for smoking behaviour, whether conception was spontaneous or with artificial reproductive technology, dilation at the moment of PPROM, latency period between PPROM and delivery, the use of tocolytics, antibiotics, corticosteroids, cervicovaginal culture results and neonatal morbidity and mortality.

RESULTS

The latency period was significantly shorter in twins (median 19 versus median 47 hours; p = 0.01) and significantly more twins were born within 48 hours after rupture of the membranes (74.2% versus 51.5%; p = 0.01). This is due to a difference in the group with gestational age 30 or less weeks, after gestational age 30 weeks no significant difference exists. No other differences were noted between groups.

CONCLUSION

No clinically relevant differences for the perinatal outcome after PPROM in twin versus singletons can be noted, but delivery is more likely to result within 48 hours after PPROM in cases of a twin pregnancy.

Scheduled relaparotomies using a zipper system for the treatment of diffuse generalized peritonitis in children

In the treatment of diffuse peritonitis, planned relaparotomies with peritoneal lavages using a zipper system (EthiZip Ethicon) are sometimes necessary to obtain a complete eradication of the infectious focus. While most reported series are dealing with an adult population, this review focuses on the treatment of peritonitis using a zipper system in a paediatric age group. In a period of 3 years, insertion of a zipper device and peritoneal lavages were considered necessary to control intraabdominal sepsis in 7 children (age varying from 5 days to 13 years). They consequently underwent planned relaparotomies with peritoneal lavages every 24 to 48 hours. The peritonitis was caused by necrotizing enterocolitis (3 patients), postoperative complications (3 patients) and long existing perforated appendicitis (1 patient). Physical status, assessed by the Acute Physiologic Score (A.P.S.), varied from 12 to 22 (mean 17.7). Usually more than one lavage was necessary (1 to 3, mean 1.9) before the abdomen was considered clean and the zipper could be removed. Closure of the abdominal cavity could be achieved primarily in all cases. All patients survived. Although no statistically significant conclusions can be drawn from this small series and although it is unclear whether these children would not have survived without the zipper, this review shows that planned relaparotomies with peritoneal lavages using a zipper system can be performed safely even in very small children.