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Fleiss N, Shabanova V, Murray TS, Gallagher PG, Bizzarro MJ. The diagnostic utility of obtaining two blood cultures for the diagnosis of early onset sepsis in neonates. J Perinatol 2024:10.1038/s41372-024-01914-6. [PMID: 38409330 DOI: 10.1038/s41372-024-01914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Noa Fleiss
- Yale School of Medicine, New Haven, CT, USA.
| | | | - Thomas S Murray
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Children's Hospital, New Haven, CT, USA
| | - Patrick G Gallagher
- Nationwide Children's Hospital, Columbus, OH, USA
- Ohio State University, Columbus, OH, USA
| | - Matthew J Bizzarro
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Children's Hospital, New Haven, CT, USA
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2
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Barrett RE, Fleiss N, Hansen C, Campbell MM, Rychalsky M, Murdzek C, Krechevsky K, Abbott M, Allegra T, Blazevich B, Dunphy L, Fox A, Gambardella T, Garcia L, Grimm N, Scoffone A, Bizzarro MJ, Murray TS. Reducing MRSA Infection in a New NICU During the COVID-19 Pandemic. Pediatrics 2023; 151:190449. [PMID: 36625072 DOI: 10.1542/peds.2022-057033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Methicillin-resistant Staphylococcus aureus (MRSA) is prevalent in most NICUs, with a high rate of skin colonization and subsequent invasive infections among hospitalized neonates. The effectiveness of interventions designed to reduce MRSA infection in the NICU during the coronavirus disease 2019 (COVID-19) pandemic has not been characterized. METHODS Using the Institute for Healthcare Improvement's Model for Improvement, we implemented several process-based infection prevention strategies to reduce invasive MRSA infections at our level IV NICU over 24 months. The outcome measure of invasive MRSA infections was tracked monthly utilizing control charts. Process measures focused on environmental disinfection and hospital personnel hygiene were also tracked monthly. The COVID-19 pandemic was an unexpected variable during the implementation of our project. The pandemic led to restricted visitation and heightened staff awareness of the importance of hand hygiene and proper use of personal protective equipment, as well as supply chain shortages, which may have influenced our outcome measure. RESULTS Invasive MRSA infections were reduced from 0.131 to 0 per 1000 patient days during the initiative. This positive shift was sustained for 30 months, along with a delayed decrease in MRSA colonization rates. Several policy and practice changes regarding personnel hygiene and environmental cleaning likely contributed to this reduction. CONCLUSIONS Implementation of a multidisciplinary quality improvement initiative aimed at infection prevention strategies led to a significant decrease in invasive MRSA infections in the setting of the COVID-19 pandemic.
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Affiliation(s)
| | - Noa Fleiss
- Yale School of Medicine, New Haven, Connecticut
| | | | | | | | | | | | - Meaghan Abbott
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Terese Allegra
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Beth Blazevich
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Louise Dunphy
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Amy Fox
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | | | - Lindsey Garcia
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Natalie Grimm
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Amy Scoffone
- Yale New Haven Children's Hospital, New Haven, Connecticut
| | | | - Thomas S Murray
- Yale School of Medicine, New Haven, Connecticut.,Yale New Haven Children's Hospital, New Haven, Connecticut
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Klunk CJ, Barrett RE, Peterec SM, Blythe E, Brockett R, Kenney M, Natusch A, Thursland C, Gallagher PG, Pando R, Bizzarro MJ. An Initiative to Decrease Laboratory Testing in a NICU. Pediatrics 2021; 148:peds.2020-000570. [PMID: 34088759 DOI: 10.1542/peds.2020-000570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period. METHODS We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time. RESULTS Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months. CONCLUSIONS Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.
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Affiliation(s)
| | - Renee E Barrett
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Steven M Peterec
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eleanor Blythe
- Yale New Haven Children's Hospital, New Haven, Connecticut; and
| | - Renee Brockett
- Yale New Haven Children's Hospital, New Haven, Connecticut; and
| | - Marta Kenney
- Yale New Haven Children's Hospital, New Haven, Connecticut; and
| | - Amber Natusch
- Yale New Haven Children's Hospital, New Haven, Connecticut; and
| | | | | | - Richard Pando
- Yale New Haven Hospital Information Technology Services, New Haven, Connecticut
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4
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Abstract
A neonate of 29 weeks' gestation who received probiotics developed clinical signs suggesting surgical necrotizing enterocolitis. A specimen of resected ileum revealed fungal forms within the bowel wall. Rhizopus oryzae was detected via DNA sequencing from probiotic powder and tissue specimens from the infant. To our knowledge, this is the first report linking gastrointestinal zygomycosis to the administration of contaminated probiotics.
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Affiliation(s)
| | | | - Raffaella A Morotti
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - John M Boyce
- Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Grossman MR, Berkwitt AK, Osborn RR, Citarella BV, Hochreiter D, Bizzarro MJ. Evaluating the effect of hospital setting on outcomes for neonatal abstinence syndrome. J Perinatol 2020; 40:1483-1488. [PMID: 32086436 DOI: 10.1038/s41372-020-0621-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/28/2020] [Accepted: 02/06/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study aims to evaluate the impact of hospital setting on outcomes for infants with neonatal abstinence syndrome. STUDY DESIGN We conducted a retrospective study in two hospitals and three different hospital units. The inpatient group (n = 60) was managed on general inpatient floors, the NICU group (n = 50) was managed primarily in an NICU, and the combination group (n = 49) was managed in both NICU and inpatient units. The primary outcome was length of stay. Secondary outcomes included breastfeeding rates, morphine usage rates, and hospital costs. RESULTS The length of stay in the inpatient group (8.5 days) was significantly lower than the combination group (18 days) and NICU group (23 days) (p < 0.01). The inpatient group had significantly lower rates of morphine treatment and hospital costs with no difference in breastfeeding rates. CONCLUSIONS Infants with neonatal abstinence syndrome had a significantly shorter length of stay and less use of morphine when managed on inpatient units versus NICU.
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Affiliation(s)
- Matthew R Grossman
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
| | - Adam K Berkwitt
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Rachel R Osborn
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Brett V Citarella
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Daniela Hochreiter
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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7
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Peterec SM, Bizzarro MJ, Mercurio MR. Is Extracorporeal Membrane Oxygenation for a Neonate Ever Ethically Obligatory? J Pediatr 2018; 195:297-301. [PMID: 29248183 DOI: 10.1016/j.jpeds.2017.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/26/2017] [Accepted: 11/06/2017] [Indexed: 11/26/2022]
Abstract
Certain interventions in the neonatal intensive care unit are considered ethically obligatory, and should be provided over parental objections. After reviewing a case, comparative outcome data, and relevant ethical principles, we propose that extracorporeal membrane oxygenation for meconium aspiration syndrome may, in some cases, be an ethically obligatory treatment.
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Affiliation(s)
- Steven M Peterec
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT.
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Mark R Mercurio
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT; Program for Biomedical Ethics, Yale University School of Medicine, New Haven, CT
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Grossman MR, Berkwitt AK, Osborn RR, Xu Y, Esserman DA, Shapiro ED, Bizzarro MJ. An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome. Pediatrics 2017; 139:peds.2016-3360. [PMID: 28562267 PMCID: PMC5470506 DOI: 10.1542/peds.2016-3360] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The incidence of neonatal abstinence syndrome (NAS), a constellation of neurologic, gastrointestinal, and musculoskeletal disturbances associated with opioid withdrawal, has increased dramatically and is associated with long hospital stays. At our institution, the average length of stay (ALOS) for infants exposed to methadone in utero was 22.4 days before the start of our project. We aimed to reduce ALOS for infants with NAS by 50%. METHODS In 2010, a multidisciplinary team began several plan-do-study-act cycles at Yale New Haven Children's Hospital. Key interventions included standardization of nonpharmacologic care coupled with an empowering message to parents, development of a novel approach to assessment, administration of morphine on an as-needed basis, and transfer of infants directly to the inpatient unit, bypassing the NICU. The outcome measures included ALOS, morphine use, and hospital costs using statistical process control charts. RESULTS There were 287 infants in our project, including 55 from the baseline period (January 2008 to February 2010) and 44 from the postimplementation period (May 2015 to June 2016). ALOS decreased from 22.4 to 5.9 days. Proportions of methadone-exposed infants treated with morphine decreased from 98% to 14%; costs decreased from $44 824 to $10 289. No infants were readmitted for treatment of NAS and no adverse events were reported. CONCLUSIONS Interventions focused on nonpharmacologic therapies and a simplified approach to assessment for infants exposed to methadone in utero led to both substantial and sustained decreases in ALOS, the proportion of infants treated with morphine, and hospital costs with no adverse events.
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Affiliation(s)
| | | | | | | | | | - Eugene D. Shapiro
- Departments of Pediatrics,,Epidemiology, Yale University School of Medicine and School of Public Health, New Haven, Connecticut
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Weismann CG, Asnes JD, Bazzy-Asaad A, Tolomeo C, Ehrenkranz RA, Bizzarro MJ. Pulmonary hypertension in preterm infants: results of a prospective screening program. J Perinatol 2017; 37:572-577. [PMID: 28206997 DOI: 10.1038/jp.2016.255] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 11/02/2016] [Accepted: 12/13/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Determine prevalence and associations with pulmonary hypertension (PH) in preterm infants. STUDY DESIGN Prospective institutional echocardiographic PH screening at 36 to 38 weeks' corrected gestational age (GA) for infants born <32 weeks' GA who had bronchopulmonary dysplasia (BPD; group BPD), and infants without BPD who had a birth weight (BW) <750 g, or clinical suspicion for PH (group NoBPD). RESULTS Two hundred and four infants were screened (GA 25.9±2 weeks, BW 831±286 g). The PH prevalence in group BPD was higher than in group NoBPD (44/159 (28%) vs 5/45 (11%); P=0.028). In group BPD, BW and GA were lower in infants with PH compared with NoPH. Following correction for BW and GA, necrotizing enterocolitis (NEC), severe intraventricular hemorrhage (IVH), atrial septal defect (ASD), and mortality were independently associated with PH in infants with BPD. In group NoBPD, NEC was the only identified factor associated with PH. Altogether, screening only those infants with NEC and infants with BPD who also had a BW <840 g would have yielded a 84% sensitivity for detecting PH, and reduced the number of screening echocardiograms by 43%. CONCLUSIONS PH in prematurity is associated with NEC in infants with and without BPD. In infants with BPD, smaller GA and BW, severe IVH, ASD and mortality are also associated with PH. Infants without identified PH-associated factors may not require routine echocardiographic PH screening.
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Affiliation(s)
- C G Weismann
- Department of Pediatrics, Division of Pediatric Cardiology, Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA.,Pediatric Heart Center, Skåne Universitetssjukhus, Lasarettgatan 48, Lund, Sweden
| | - J D Asnes
- Department of Pediatrics, Division of Pediatric Cardiology, Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - A Bazzy-Asaad
- Department of Pediatrics, Section of Pediatric Respiratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - C Tolomeo
- Department of Pediatrics, Section of Pediatric Respiratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - R A Ehrenkranz
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - M J Bizzarro
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Abstract
Central line-associated bloodstream infections (CLABSI) are among the most common healthcare-acquired infections in the neonatal intensive care unit (NICU) population and are associated with an increased risk of morbidity and mortality, as well as increased healthcare costs, and duration of hospitalization. Over the past decade, numerous local, statewide, and national quality improvement initiatives have resulted in a significant reduction in CLABSI rates. The majority of successful initiatives have utilized similar strategies to implement and sustain their efforts, including education of NICU staff in the principles of quality improvement, creation and implementation of central line insertion and maintenance bundles and methods for assessing compliance, formation of dedicated central line insertion and maintenance teams, and utilization of reliable and effective methods for collecting, analyzing, and displaying data. Despite this progress, continued work toward discovery of better practices, such as the safest and most effective agent for cutaneous antisepsis or identification of optimal outcome and process measures, is required if further progress is to be made. Additionally, sustained progress in reducing the burden of neonatal infections may require a shift in focus away from CLABSI and toward the reporting, investigation, and prevention of all NICU-onset bacteremia.
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Affiliation(s)
- Renée E Mobley
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT.
| | - Matthew J Bizzarro
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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12
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Levit OL, Shabanova V, Bazzy-Asaad A, Bizzarro MJ, Bhandari V. Risk factors for tracheostomy requirement in extremely low birth weight infants. J Matern Fetal Neonatal Med 2017; 31:447-452. [PMID: 28139937 DOI: 10.1080/14767058.2017.1287895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM To identify variables that affect the risk of tracheostomy in a population of extremely low birth weight (ELBW) infants. METHODS A retrospective matched case-control study was conducted. ELBW infants with a tracheostomy were compared with controls without tracheostomy. Data collection included demographics, detailed information about each intubation and extubation attempt, the use of steroids and the presence of comorbidities. Statistical analyses include conditional logistic regression and Poisson regression for clustered observations. RESULTS Twenty-eight ELBW infants with a tracheostomy were identified. Mean gestational age for both cases and controls was 25 weeks (22-29) and 67.9% were males. Tracheostomy was performed on average on day of life 118 (95%CI: 107-128) and weight at tracheostomy was 2877 g (95%CI: 2657-3098). In the final model, cumulative days with an endotracheal tube (ETT) and total number of intubation episodes were associated with a tracheostomy. For each additional day of intubation, odds of tracheostomy increased by 11% (OR = 1.11, 95%CI: 1.01, 1.23) and with each new intubation episode/failed extubation episode, odds of tracheostomy increased by 150% from the previous episode (OR = 2.5, 95%CI: 1.2, 5.2). CONCLUSIONS Greater cumulative exposure to ETT ventilation and number of intubations is associated with having a tracheostomy.
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Affiliation(s)
- Orly L Levit
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | | | - Alia Bazzy-Asaad
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | - Matthew J Bizzarro
- a Department of Pediatrics , Yale University School of Medicine , New Haven , CT , USA
| | - Vineet Bhandari
- c Department of Pediatrics , Drexel University College of Medicine , Philadelphia , PA , USA
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Bizzarro MJ, Lefton-Greif MA, McGinley BM, Siner JM. FIRST, "KNOW" HARM: Response to Letter to the Editor. Dysphagia 2016; 31:783-785. [PMID: 27638423 DOI: 10.1007/s00455-016-9748-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022]
Affiliation(s)
| | - Maureen A Lefton-Greif
- Departments of Pediatrics, Otolaryngology-Head and Neck Surgery, and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Brian M McGinley
- Division of Pediatric Pulmonary and Sleep Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jonathan M Siner
- Department of Pulmonary and Critical Care, Yale School of Medicine, New Haven, CT, USA
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14
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Montgomery AM, Bazzy-Asaad A, Asnes JD, Bizzarro MJ, Ehrenkranz RA, Weismann CG. Biochemical Screening for Pulmonary Hypertension in Preterm Infants with Bronchopulmonary Dysplasia. Neonatology 2016; 109:190-4. [PMID: 26780635 DOI: 10.1159/000442043] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) in infants with bronchopulmonary dysplasia (BPD) is associated with increased morbidity and mortality. Elevated levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and decreased levels of amino acid precursors of nitric oxide (NO) have been associated with PH, but have not been studied in infants with PH secondary to BPD. OBJECTIVE The aim of this study was to identify a biochemical marker for PH in infants with BPD. METHODS Twenty infants, born at <27 weeks' gestational age (GA) and/or with a birth weight (BW) ≤750 g, who met the criteria for BPD at 36 weeks' corrected GA (CGA) were enrolled in this cross-sectional pilot study. A screening echocardiogram was conducted at 36-38 weeks' CGA and plasma NT-proBNP and amino acid levels were obtained within 1 week of the screening echocardiogram. RESULTS Five infants (25%) had echocardiographic evidence of PH. GA and BW were not significantly different between the 2 groups (a PH group and a No PH group). NT-proBNP was significantly elevated in the PH group (median 1,650 vs. 520 pg/ml; p = 0.001) but citrulline levels were significantly lower (median 21 vs. 36 μmol/l; p = 0.005). Arginine levels were not significantly different between the groups (median 78 vs. 79 μmol/l; p = 1). CONCLUSION NT-proBNP and the NO precursor citrulline may be cost-effective biochemical markers for screening for the presence of PH in preterm infants who have BPD. If validated in a larger study, such biochemical markers may, in part, replace PH screening echocardiograms in these patients.
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Affiliation(s)
- Angela M Montgomery
- Section of Neonatal-Perinatal Medicine, Yale University School of Medicine, New Haven, Conn., USA
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Bizzarro MJ, Shabanova V, Baltimore RS, Dembry LM, Ehrenkranz RA, Gallagher PG. Neonatal sepsis 2004-2013: the rise and fall of coagulase-negative staphylococci. J Pediatr 2015; 166:1193-9. [PMID: 25919728 PMCID: PMC4413005 DOI: 10.1016/j.jpeds.2015.02.009] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/12/2014] [Accepted: 02/04/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate data for the period 2004-2013 to identify changes in demographics, pathogens, and outcomes in a single, level IV neonatal intensive care unit. STUDY DESIGN Sepsis episodes were identified prospectively and additional information obtained retrospectively from infants with sepsis while in the neonatal intensive care unit from 2004 to 2013. Demographics, hospital course, and outcome data were collected and analyzed. Sepsis was categorized as early (≤3 days of life) or late-onset (>3 days of life). RESULTS Four hundred fifty-two organisms were identified from 410 episodes of sepsis in 340 infants. Ninety percent of cases were late-onset. Rates of early-onset sepsis remained relatively static throughout the study period (0.9 per 1000 live births). For the first time in decades, most (60%) infants with early-onset sepsis were very low birth weight and Escherichia coli (45%) replaced group B streptococcus (36%) as the most common organism associated with early-onset sepsis. Rates of late-onset sepsis, particularly due to coagulase-negative staphylococci, decreased significantly after implementation of several infection-prevention initiatives. Coagulase-negative staphylococci were responsible for 31% of all cases from 2004 to 2009 but accounted for no cases of late-onset sepsis after 2011. CONCLUSIONS The epidemiology and microbiology of early- and late-onset sepsis continue to change, impacted by targeted infection prevention efforts. We believe the decrease in sepsis indicates that these interventions have been successful, but additional surveillance and strategies based on evolving trends are necessary.
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Affiliation(s)
| | - Veronika Shabanova
- Department of Epidemiology and Public Health, Yale University School of Medicine
| | - Robert S. Baltimore
- Department of Pediatrics, Yale University School of Medicine,Department of Epidemiology and Public Health, Yale University School of Medicine,Department of Quality Improvement Support Services, Yale-New Haven Hospital
| | - Louise-Marie Dembry
- Department of Quality Improvement Support Services, Yale-New Haven Hospital,Department of Internal Medicine, Yale University School of Medicine
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Bizzarro MJ, Sabo B, Noonan M, Bonfiglio MP, Northrup V, Diefenbach K. A Quality Improvement Initiative to Reduce Central Line–Associated Bloodstream Infections in a Neonatal Intensive Care Unit. Infect Control Hosp Epidemiol 2015; 31:241-8. [DOI: 10.1086/650448] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To reduce the rate of late-onset sepsis in a neonatal intensive care unit (NICU) by decreasing the rate of central line–associated bloodstream infection (CLABSI).Methods.We conducted a quasi-experimental study of an educational intervention designed to improve the quality of clinical practice in an NICU. Participants included all NICU patients with a central venous catheter (CVC). Data were collected during the period from July 1, 2005, to June 30, 2007, to document existing CLABSI rates and CVC-related practices. A multidisciplinary quality improvement committee was established to review these and published data and to create guidelines for CVC placement and management. Educational efforts were conducted to implement these practices. Postintervention CLABSI rates were collected during the period from January 1, 2008, through March 31, 2009, and compared with preintervention data and with benchmark data from the National Healthcare Safety Network (NHSN).Results.The rate of CLABSI in the NICU decreased from 8.40 to 1.28 cases per 1,000 central line–days (adjusted rate ratio, 0.19 [95% confidence interval, 0.08–0.45]). This rate was lower than the NHSN benchmark rate for level III NICUs. The overall rate of late-onset sepsis was reduced from 5.84 to 1.42 cases per 1,000 patient-days (rate difference, −4.42 cases per 1,000 patient-days [95% confidence interval, −5.55 to −3.30 cases per 1,000 patient-days]).Conclusions.It is possible to reduce the rate of CLABSI, and therefore the rate of late-onset sepsis, by establishing and adhering to evidence-based guidelines. Sustainability depends on continued data surveillance, knowledge of medical and nursing literature, and timely feedback to the staff. The techniques established are applicable to other populations and areas of inpatient care.
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Khattab M, Cannon-Heinrich C, Bizzarro MJ. Ear drainage and the role of sepsis evaluations in the neonatal intensive care unit. Acta Paediatr 2014; 103:732-6. [PMID: 24635016 DOI: 10.1111/apa.12636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/27/2014] [Accepted: 03/12/2014] [Indexed: 11/28/2022]
Abstract
AIM To design and implement an intervention to reduce ear drainage and subsequent sepsis evaluation and treatment in the neonatal intensive care unit. METHODS From 2008 to 2011, we observed an increase in the rates of ear drainage warranting investigation. Data collection was performed from 1991 to 2013 on 50 cases. Preliminary analysis revealed an association between timing of endotracheal tube tape changes and onset of drainage. We speculated that pooling of anti-adhesive solution into the external auditory canal was precipitating an inflammatory process. Unit-wide education was conducted to protect the ears during tape removal. Post-initiative rates of drainage were collected and compared with pre-initiative rates. RESULTS Median gestational age and birthweight were 26 weeks and 754 g, respectively. In 64% of cases, an anti-adhesive solution was used on the face within 48 h of the onset of drainage. Sepsis evaluation was performed in 68% of cases. Rates of ear drainage peaked from 2008 to 2011 at 9.18 per 1000 admissions when a new anti-adhesive product was used, declining to 0.66 post-initiative (rate difference: -8.52; 95% CI: -12.00, -5.03). CONCLUSION Protecting the ear from anti-adhesive solutions during tape removal may reduce rates of noninfectious ear drainage and limit unnecessary interventions.
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Affiliation(s)
- Mona Khattab
- Department of Pediatrics; Baylor College of Medicine; Houston TX USA
| | | | - Matthew J. Bizzarro
- Department of Pediatrics; Yale University School of Medicine; New Haven CT USA
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Levit OL, Calkins KL, Gibson LC, Kelley-Quon L, Robinson DT, Elashoff DA, Grogan TR, Li N, Bizzarro MJ, Ehrenkranz RA. Low-Dose Intravenous Soybean Oil Emulsion for Prevention of Cholestasis in Preterm Neonates. JPEN J Parenter Enteral Nutr 2014; 40:374-82. [PMID: 24963025 DOI: 10.1177/0148607114540005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/16/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Premature infants depend on intravenous fat emulsions to supply essential fatty acids and calories. The dose of soybean-based intravenous fat emulsions (S-IFE) has been associated with parenteral nutrition (PN)-associated liver disease. This study's purpose was to determine if low-dose S-IFE is a safe and effective preventive strategy for cholestasis in preterm neonates. MATERIALS AND METHODS This is a multicenter randomized controlled trial in infants with a gestational age (GA) ≤29 weeks. Patients <48 hours of life were randomized to receive a low (1 g/kg/d) or control dose (approximately 3 g/kg/d) of S-IFE. The primary outcome was cholestasis, defined as a direct bilirubin ≥15% of the total bilirubin at 28 days of life (DOL) or full enteral feeds, whichever was later, after 14 days of PN. Secondary outcomes included growth, length of hospital stay, death, and major neonatal morbidities. RESULTS In total, 136 neonates (67 and 69 in the low and control groups, respectively) were enrolled. Baseline characteristics were similar for the 2 groups. When the low group was compared with the control group, there was no difference in the primary outcome (69% vs 63%; 95% confidence interval, -0.1 to 0.22; P = .45). While the low group received less S-IFE and total calories over time compared with the control group (P < .001 and P = .03, respectively), weight, length, and head circumference at 28 DOL, discharge, and over time were not different (P > .2 for all). CONCLUSION Compared with the control dose, low-dose S-IFE was not associated with a reduction in cholestasis or growth.
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Affiliation(s)
- Orly L Levit
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Kara L Calkins
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - L Caroline Gibson
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Lorraine Kelley-Quon
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Daniel T Robinson
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David A Elashoff
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tristan R Grogan
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Ning Li
- Department of Biomathematics, University of California, Los Angeles, California
| | - Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Richard A Ehrenkranz
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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Levit O, Bhandari V, Li FY, Shabanova V, Gallagher PG, Bizzarro MJ. Clinical and laboratory factors that predict death in very low birth weight infants presenting with late-onset sepsis. Pediatr Infect Dis J 2014; 33:143-6. [PMID: 24418836 PMCID: PMC3917323 DOI: 10.1097/inf.0000000000000024] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Late-onset sepsis (LOS) in very low birth weight (VLBW) infants is associated with significant morbidity and mortality. The ability to predict mortality in infants with LOS based on clinical and laboratory factors at presentation of illness remains limited. OBJECTIVES To identify predictors of sepsis-associated mortality from a composite risk profile that includes demographic data, category of infecting organism, clinical and laboratory data at onset of illness. STUDY DESIGN Data were collected from VLBW infants with at least 1 episode of LOS admitted to Yale Neonatal Intensive Care Unit from 1989 through 2007. Episodes were categorized as Gram-positive, Gram-negative or fungal. Multivariate logistic regression analysis was used to compare and contrast different types of infections and to assess independent risk factors for death. RESULTS Four hundred twenty-four cases of LOS were identified in 424 VLBW infants. Of these, 262 (62%) were categorized as Gram-positive, 126 (30%) as Gram-negative and 36 (8%) as fungal. Multivariate analyses revealed that infants with Gram-positive infections had significantly lower odds of death compared to those with Gram-negative (adjusted odds ratio: 0.17; 95% confidence interval: 0.08-0.36) or fungal LOS (adjusted odds ratio: 0.22; 95% confidence interval: 0.07-0.64). Need for intubation, initiation of pressors, hypoglycemia and thrombocytopenia as presenting laboratory signs of infection and necrotizing enterocolitis were independent risk factors for sepsis-related death. CONCLUSIONS We identified presenting clinical and laboratory factors, including category of infecting organism, which predict the increased risk of LOS-related death. This information can be useful in estimating prognosis shortly after the onset of disease.
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Affiliation(s)
- Orly Levit
- Yale-University School of Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT,Address for correspondence: Orly Levit, MD, Department of Pediatrics – Yale University, 333 Cedar Street, New Haven, CT 06510, Phone: 203- 688-2320, Fax: 203-688-5426,
| | - Vineet Bhandari
- Yale-University School of Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Fang-Yong Li
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Veronika Shabanova
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Patrick G. Gallagher
- Yale-University School of Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Matthew J. Bizzarro
- Yale-University School of Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Szafranski P, Yang Y, Nelson MU, Bizzarro MJ, Morotti RA, Langston C, Stankiewicz P. Novel FOXF1 deep intronic deletion causes lethal lung developmental disorder, alveolar capillary dysplasia with misalignment of pulmonary veins. Hum Mutat 2013; 34:1467-71. [PMID: 23943206 DOI: 10.1002/humu.22395] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/05/2013] [Indexed: 01/05/2023]
Abstract
Haploinsufficiency of FOXF1 causes an autosomal dominant neonatally lethal lung disorder, alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV). We identified novel 0.8-kb deletion within the 1.4-kb intron of FOXF1 in a deceased newborn diagnosed with ACDMPV. The deletion arose de novo on the maternal copy of the chromosome 16, and did not affect FOXF1 minigene splicing tested in lung fibroblasts. However, FOXF1 transcript level in the ACDMPV peripheral lung tissue was reduced by almost 40%. We found that, in an in vitro reporter assay, the FOXF1 intron exhibited moderate transcriptional enhancer activity, correlating with the presence of binding sites for expression regulators CTCF and CEBPB, whereas its truncated copy, which lost major CTCF and CEBPB-binding sites, inhibited the FOXF1 promoter. Our data further emphasize the importance of testing the non-protein coding regions of the genome currently not covered by diagnostic chromosomal microarray analyses or whole-exome sequencing.
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Affiliation(s)
- Przemyslaw Szafranski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, 77030
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Nelson MU, Maksimova Y, Schulz V, Bizzarro MJ, Gallagher PG. Late-onset Leclercia adecarboxylata sepsis in a premature neonate. J Perinatol 2013; 33:740-2. [PMID: 23986093 DOI: 10.1038/jp.2013.34] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/15/2013] [Indexed: 12/22/2022]
Abstract
The epidemiology, etiology and outcome of neonatal sepsis are changing over time. While monitoring longitudinal trends in neonatal sepsis in our institution, we encountered a case of late-onset neonatal sepsis due to Leclercia adecarboxylata. A Gram-negative rod previously not encountered in the clinical setting, L. adecarboxylata has recently emerged as a human pathogen, primarily in immunosuppressed patients. This report describes the clinical and laboratory features of this case of late-onset L. adecarboxylata sepsis, and reviews significant features of infection associated with this emerging pathogen.
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Affiliation(s)
- M U Nelson
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520, USA
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Abstract
Health care-associated infections often result in significant morbidity and mortality to affected patients and substantial financial cost to an overburdened health care system. Local, statewide, and national efforts have been conducted to eradicate central line-associated infections, ventilator-associated pneumonia, and urinary tract infections from inpatient and outpatient facilities. In the neonatal intensive care unit population, significant improvements have been made in many areas, but have been hindered in others by a lack of population-specific definitions, data, and guidelines for prevention and management. Therefore, more concerted efforts are needed in these areas for continued progress to occur.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA.
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Colacchio K, Deng Y, Northrup V, Bizzarro MJ. Complications associated with central and non-central venous catheters in a neonatal intensive care unit. J Perinatol 2012; 32:941-6. [PMID: 22343397 DOI: 10.1038/jp.2012.7] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study is to compare complication rates between peripherally inserted central catheters (PICCs) and peripherally inserted non-central catheters (PINCCs) in the neonatal intensive care unit (NICU). STUDY DESIGN A retrospective, observational study was conducted. The PICCs were catheters whose tip terminated in the vena cavae, and PINCCs were defined as those whose tip fell short of this location. Complication rates were assessed using generalized estimating equations modeling. RESULT A total of 91 PINCCs and 889 PICCs were placed in 750 neonates. In all, 44.0% of PINCCs had a major complication compared with 25.2% of PICCs (P=0.0001). The unadjusted (unadj.) complication rate among PINCCs was 51.7 per 1000 line days and 15.9 for PICCs (unadj. rate ratio: 3.25; 95% confidence interval (CI): 2.32, 4.55). After adjusting for multiple confounders, the risk remained significantly higher for PINCCs (adjusted odds ratio: 2.41; 95% CI: 1.33, 4.37). CONCLUSION The rate of associated complications with the use of PINCCs in the NICU population is more than twice that of the PICCs.
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Affiliation(s)
- K Colacchio
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Alexander VN, Northrup V, Bizzarro MJ. Antibiotic exposure in the newborn intensive care unit and the risk of necrotizing enterocolitis. J Pediatr 2011; 159:392-7. [PMID: 21489560 PMCID: PMC3137655 DOI: 10.1016/j.jpeds.2011.02.035] [Citation(s) in RCA: 264] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 02/07/2011] [Accepted: 02/24/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine whether duration of antibiotic exposure is an independent risk factor for necrotizing enterocolitis (NEC). STUDY DESIGN A retrospective, 2:1 control-case analysis was conducted comparing neonates with NEC to those without from 2000 through 2008. Control subjects were matched on gestational age, birth weight, and birth year. In each matched triad, demographic and risk factor data were collected from birth until the diagnosis of NEC in the case subject. Bivariate and multivariate analyses were used to assess associations between risk factors and NEC. RESULTS One hundred twenty-four cases of NEC were matched with 248 control subjects. Cases were less likely to have respiratory distress syndrome (P = .018) and more likely to reach full enteral feeding (P = .028) than control subjects. Cases were more likely to have culture-proven sepsis (P < .0001). Given the association between sepsis and antibiotic use, we tested for and found a significant interaction between the two variables (P = .001). When neonates with sepsis were removed from the cohort, the risk of NEC increased significantly with duration of antibiotic exposure. Exposure for >10 days resulted in a nearly threefold increase in the risk of developing NEC. CONCLUSIONS Duration of antibiotic exposure is associated with an increased risk of NEC among neonates without prior sepsis.
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Abstract
The objective of this study was to examine the use of partial exchange transfusion (PET) performed for polycythemia hyperviscosity syndrome (PHS) over time. A retrospective review of 141 infants who received a PET for PHS at Yale-New Haven Hospital between 1986 and 2007 was performed, querying maternal and neonatal medical records. Patient demographics, risk factors for PHS, indications for PET, and complications associated with PET and PHS were collected. Overall, there was no change in the number of PET performed over the study period ( R(2)=0.082, P=0.192). Eighty-eight percent of patients had at least one risk factor for PHS, most commonly maternal diabetes. Over time, there was a statistically significant decrease in maternal diabetes as a risk factor for PHS. Forty percent of patients had a significant complication attributed to PHS prior to PET. Eighteen percent of patients had a complication attributed to PET. Life-threatening complications of PHS or PET were rare. In conclusion, PHS continues to be a problem observed in neonatal intensive care units, particularly in at-risk populations. PHS and PET are associated with significant complications. Well-designed studies with long-term follow up are needed to assess the risks and benefits of PET for PHS.
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Affiliation(s)
- Bridget Hopewell
- Yale University School of Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
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29
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Stoll BJ, Hansen NI, Sánchez PJ, Faix RG, Poindexter BB, Van Meurs KP, Bizzarro MJ, Goldberg RN, Frantz ID, Hale EC, Shankaran S, Kennedy K, Carlo WA, Watterberg KL, Bell EF, Walsh MC, Schibler K, Laptook AR, Shane AL, Schrag SJ, Das A, Higgins RD. Early onset neonatal sepsis: the burden of group B Streptococcal and E. coli disease continues. Pediatrics 2011; 127:817-26. [PMID: 21518717 PMCID: PMC3081183 DOI: 10.1542/peds.2010-2217] [Citation(s) in RCA: 707] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Guidelines for prevention of group B streptococcal (GBS) infection have successfully reduced early onset (EO) GBS disease. Study results suggest that Escherichia coli is an important EO pathogen. OBJECTIVE To determine EO infection rates, pathogens, morbidity, and mortality in a national network of neonatal centers. METHODS Infants with EO infection were identified by prospective surveillance at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Network centers. Infection was defined by positive culture results for blood and cerebrospinal fluid obtained from infants aged ≤72 hours plus treatment with antibiotic therapy for ≥5 days. Mother and infant characteristics, treatments, and outcomes were studied. Numbers of cases and total live births (LBs) were used to calculate incidence. RESULTS Among 396 586 LBs (2006-2009), 389 infants developed EO infection (0.98 cases per 1000 LBs). Infection rates increased with decreasing birth weight. GBS (43%, 0.41 per 1000 LBs) and E coli (29%, 0.28 per 1000 LBs) were most frequently isolated. Most infants with GBS were term (73%); 81% with E coli were preterm. Mothers of 67% of infected term and 58% of infected preterm infants were screened for GBS, and results were positive for 25% of those mothers. Only 76% of mothers with GBS colonization received intrapartum chemoprophylaxis. Although 77% of infected infants required intensive care, 20% of term infants were treated in the normal newborn nursery. Sixteen percent of infected infants died, most commonly with E coli infection (33%). CONCLUSION In the era of intrapartum chemoprophylaxis to reduce GBS, rates of EO infection have declined but reflect a continued burden of disease. GBS remains the most frequent pathogen in term infants, and E coli the most significant pathogen in preterm infants. Missed opportunities for GBS prevention continue. Prevention of E coli sepsis, especially among preterm infants, remains a challenge.
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Affiliation(s)
- Barbara J. Stoll
- Emory University School of Medicine, Department of Pediatrics, and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nellie I. Hansen
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
| | - Pablo J. Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roger G. Faix
- Department of Pediatrics, Division of Neonatology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krisa P. Van Meurs
- Division of Neonatology, Stanford University Medical Center, Palo Alto, California
| | - Matthew J. Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | | | - Ivan D. Frantz
- Department of Pediatrics, Tufts Medical Center, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
| | - Ellen C. Hale
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Kathleen Kennedy
- Department of Pediatrics, University of Texas Medical School at Houston, Texas
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kristi L. Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Kurt Schibler
- Department of Pediatrics, University of Cincinnati, Ohio
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Andi L. Shane
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
OBJECTIVE Owing to resident work-hour reductions and more permanent personnel in the newborn intensive care unit (NICU), we sought to determine if pediatric housestaff are missing learning opportunities in procedural training due to non-participation. STUDY DESIGN A prospective, observational study was conducted at an academic NICU using self-reported data from neonatal personnel after attempting 188 procedures on 109 neonates, and analyzed using Fisher's exact and χ (2)-tests. RESULT Housestaff first attempted 32% of procedures (P<0.001) and were less likely to make attempts early in the academic year (P<0.001). There was no significant difference in attempts based on urgency of situation (P=0.742). Of procedures performed by non-housestaff personnel, 93% were completed while housestaff were present elsewhere in the unit. CONCLUSION Pediatric housestaff performed the minority of procedures in the NICU, even in non-urgent situations, and were often uninvolved in other procedures, representing missed learning opportunities.
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Affiliation(s)
- Y F Gozzo
- Division of Neonatal and Perinatal Medicine, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Abstract
Previous studies to identify a genetic component to RDS have shown conflicting results. Our objectives were to evaluate and quantify the genetic contribution to RDS using data that comprehensively includes known environmental factors in a large sample of premature twins. Data from a retrospective chart review of twins born at < or =32 wk GA were obtained from two neonatal units. Mixed effects logistic regression (MELR) analysis was used to assess the influence of several independent covariates on RDS. A zygosity analysis, including the effects of additive genetic, common environmental and residual effects (ACE) factors, was performed to estimate the genetic contribution. Results reveal that the 332 twin pairs had a mean GA of 29.5 wk and birth weight (BW) of 1372 g. An MELR identified significant nongenetic covariates as male gender (p = 0.04), BW (p < 0.001), 5-min Apgar score (p < 0.001), and treating institution (p = 0.001) as significant predictors for RDS. The ACE model was used to estimate the genetic susceptibility to RDS by adjusting for the above factors. We found 49.7% (p = 0.04) of the variance in liability to RDS was the result of genetic factors alone. We conclude that there is a significant genetic susceptibility to RDS in preterm infants.
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Affiliation(s)
- Orly Levit
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Bilguvar K, DiLuna ML, Bizzarro MJ, Bayri Y, Schneider KC, Lifton RP, Gunel M, Ment LR. COL4A1 mutation in preterm intraventricular hemorrhage. J Pediatr 2009; 155:743-5. [PMID: 19840616 PMCID: PMC2884156 DOI: 10.1016/j.jpeds.2009.04.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Revised: 03/05/2009] [Accepted: 04/08/2009] [Indexed: 11/29/2022]
Abstract
Intraventricular hemorrhage is a common complication of preterm infants. Mutations in the type IV procollagen gene, COL4A1, are associated with cerebral small vessel disease with hemorrhage in adults and fetuses. We report a rare variant in COL4A1 associated with intraventricular hemorrhage in dizygotic preterm twins. These results expand the spectrum of diseases attributable to mutations in type IV procollagens.
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MESH Headings
- Cerebral Hemorrhage/diagnostic imaging
- Cerebral Hemorrhage/genetics
- Collagen Type IV/genetics
- Diseases in Twins/diagnostic imaging
- Diseases in Twins/genetics
- Female
- Follow-Up Studies
- Gene Expression Regulation, Developmental
- Genetic Predisposition to Disease
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/genetics
- Male
- Mutation
- Pregnancy
- Twins, Dizygotic
- Ultrasonography, Doppler, Transcranial
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Abstract
OBJECTIVE To explore how neonates with respiratory failure are selected for extracorporeal membrane oxygenation (ECMO) once severity of illness criteria are met, and to determine how conflicts between ECMO providers and parents over the initiation of ECMO are addressed. STUDY DESIGN A cross-sectional study was conducted using a data collection survey, which was sent to the directors of neonatal respiratory ECMO centers. RESULT The lowest birth weight and gestational age at which respondents would consider placing a neonate on ECMO were frequently below recommended thresholds. There was wide variability in respondents' willingness to place neonates on ECMO in the presence of conditions such as intraventricular hemorrhage and hypoxic ischemic encephalopathy. The number of respondents who would never seek to override parental refusal of ECMO was equal to the number who would always do so. CONCLUSION Significant variability exists in the selection criteria for neonatal ECMO and in how conflicts with parents over the provision of ECMO are resolved.
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Affiliation(s)
- R L Chapman
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - S M Peterec
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA,Department of Pediatrics, Lawrence & Memorial Hospital, New London, CT, USA,Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, PO Box 208064, New Haven, CT 06520-5426, USA. E-mail:
| | - M J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - M R Mercurio
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA,Yale Pediatric Ethics Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
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Bizzarro MJ, Copel JA, Pearson HA, Pober B, Bhandari V. Pulmonary hypoplasia and persistent pulmonary hypertension in the newborn with homozygous α-thalassemia: a case report and review of the literature. J Matern Fetal Neonatal Med 2009; 14:411-6. [PMID: 15061322 DOI: 10.1080/14767050412331312280] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The survival of infants with homozygous alpha-thalassemia, once considered a lethal diagnosis, is now possible through in utero and postnatal diagnostic and therapeutic interventions. We report the survival of a newborn with homozygous alpha-thalassemia complicated by pulmonary hypoplasia and persistent pulmonary hypertension, an association not previously reported.
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Affiliation(s)
- M J Bizzarro
- Department of Pediatrics, Yale-New Haven Hospital, New Haven, Connecticut, USA
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Abstract
BACKGROUND The most common congenital heart disease in the newborn population, patent ductus arteriosus, accounts for significant morbidity in preterm newborns. In addition to prematurity and environmental factors, we hypothesized that genetic factors play a significant role in this condition. OBJECTIVE The objective of this study was to quantify the contribution of genetic factors to the variance in liability for patent ductus arteriosus in premature newborns. PATIENTS AND METHODS A retrospective study (1991-2006) from 2 centers was performed by using zygosity data from premature twins born at < or =36 weeks' gestational age and surviving beyond 36 weeks' postmenstrual age. Patent ductus arteriosus was diagnosed by echocardiography at each center. Mixed-effects logistic regression was used to assess the effect of specific covariates. Latent variable probit modeling was then performed to estimate the heritability of patent ductus arteriosus, and mixed-effects probit modeling was used to quantify the genetic component. RESULTS We obtained data from 333 dizygotic twin pairs and 99 monozygotic twin pairs from 2 centers (Yale University and University of Connecticut). Data on chorioamnionitis, antenatal steroids, gestational age, body weight, gender, respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, oxygen supplementation, and bronchopulmonary dysplasia were comparable between monozygotic and dizygotic twins. We found that gestational age, respiratory distress syndrome, and institution were significant covariates for patent ductus arteriosus. After controlling for specific covariates, genetic factors or the shared environment accounted for 76.1% of the variance in liability for patent ductus arteriosus. CONCLUSIONS Preterm patent ductus arteriosus is highly familial (contributed to by genetic and environmental factors), with the effect being mainly environmental, after controlling for known confounders.
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Affiliation(s)
- Vineet Bhandari
- Yale University School of Medicine, Department of Pediatrics, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064, USA.
| | - Gongfu Zhou
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew J. Bizzarro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Catalin Buhimschi
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut
| | - Naveed Hussain
- Division of Neonatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Jeffrey R. Gruen
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut,Department of Genetics, Yale University School of Medicine, New Haven, Connecticut,Department of Investigative Medicine, Yale University School of Medicine, New Haven, Connecticut,Department of Yale Child Health Research Center, Yale University School of Medicine, New Haven, Connecticut
| | - Heping Zhang
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
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Bizzarro MJ, Dembry LM, Baltimore RS, Gallagher PG. Matched case-control analysis of polymicrobial bloodstream infection in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2008; 29:914-20. [PMID: 18808341 DOI: 10.1086/591323] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare and contrast the epidemiology of polymicrobial and monomicrobial bloodstream infections (BSIs) in newborn intensive care unit (NICU) patients. DESIGN Retrospective, matched case-control study. SETTING The Yale-New Haven Hospital NICU from 1989 through 2006. SUBJECTS NICU patients with BSIs. METHODS Each neonate with polymicrobial BSI (case patient) was matched to one neonate with monomicrobial BSI (control patient), by birth date, weight, and sex; and univariate and multivariate analyses were performed. RESULTS One hundred five cases of polymicrobial BSI were identified in 102 infants, representing 10% of all neonatal BSIs in our institution. Coagulase-negative staphylococci were the most common organisms recovered from culture. Infants with polymicrobial BSI had later onset of infection than infants with monomicrobial BSI (mean day of life, 37.5 vs 24.0; P<.001). Polymicrobial BSI occurred more frequently among infants with a severe underlying condition than in those without such a condition (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.2) and among infants requiring an indwelling central venous catheter for a prolonged duration (mean, 16.9 days, compared with 9.8 days for infants with monomicrobial BSI; P=.001). Multivariate analysis revealed that later onset of infection (adjusted OR [aOR], 1.02; 95% CI, 1.00-1.04) and presence of a severe underlying condition (aOR, 1.91; 95% CI, 1.12-3.38) were independent risk factors for polymicrobial BSI. No differences in outcome or mortality were observed. CONCLUSIONS Changes in the microbiology and epidemiology of NICU-related polymicrobial BSI have occurred since the last North American review. In the present study, although differences were observed, most risk factors and outcomes were similar between monomicrobial BSI and polymicrobial BSI. Epidemiologic surveillance is critical to identify trends associated with neonatal polymicrobial BSI, particularly those that may impact preventative strategies, diagnostic measures, and therapeutic interventions.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA
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Abstract
Necrotizing enterocolitis (NEC) is primarily a disease process of the gastrointestinal (GI) tract of premature neonates that results in inflammation and bacterial invasion of the bowel wall. Despite advances in the care of premature infants, NEC remains one of the leading causes of morbidity and mortality in this population. It occurs in 1-5% of all neonatal intensive care admissions and 5-10% of all very low birthweight (<1500 g) infants. Although research has presented an interesting array of potential contributing factors, the precise aetiology of this multifactorial disease process remains elusive. Historically, it was believed that NEC arose predominantly from ischaemic injury to the immature GI tract, yet alternate plausible hypotheses indicate that many factors are likely to be involved. These may include issues related to the introduction and advancement of enteric feeding, alterations in the normal bacterial colonization of the GI tract, bacterial translocation and activation of the cytokine cascade, decreased epidermal growth factor, increased platelet activating factor, and mucosal damage from free radical production. Clinical manifestations of NEC may be vague, including increased episodes of apnoea, desaturations, bradycardia, lethargy and temperature instability. There may also be GI-specific symptoms such as feeding intolerance, emesis, bloody stools, abdominal distention and tenderness, and abdominal wall discolouration. Laboratory values may be indicative of infection, coagulation abnormalities and fluid retention. Radiographic signs may include ileus, dilated or fixed intestinal loops, air in the intestinal wall or free air in the abdomen. Medical treatment typically consists of bowel rest and decompression, antibacterial therapy, and management of other haematological or electrolyte imbalances. Increased respiratory and cardiovascular support is sometimes needed. In neonates who do not respond adequately to medical management, or if pneumoperitoneum is present, surgical intervention may occur with either use of a peritoneal drain or laparotomy. Advances in antenatal and neonatal care have resulted in increased survival of extremely preterm neonates. As this at-risk population continues to increase, an effective preventative strategy for NEC is needed. One preventative strategy is the use of antenatal corticosteroids to enhance maturation of the fetus if preterm delivery is likely. Recommendation of use of breast milk, early initiation of trophic feeds and judicoius advancement of enteric feeds are current postnatal strategies. Other preventative strategies that have been investigated include the use of oral antibacterials, antioxidants, supplementation of arginine and epidermal growth factor, none of which have changed clinical practice. Recent promising data indicate that prophylactic use of probiotics may play a role in preventing the onset of NEC. However, more large-scale, definitive studies are needed.
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Affiliation(s)
- Alecia M Thompson
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA
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Bizzarro MJ, Dembry LM, Baltimore RS, Gallagher PG. Changing patterns in neonatal Escherichia coli sepsis and ampicillin resistance in the era of intrapartum antibiotic prophylaxis. Pediatrics 2008; 121:689-96. [PMID: 18381532 DOI: 10.1542/peds.2007-2171] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to determine current trends in Escherichia coli-related early- and late-onset sepsis and patterns of ampicillin resistance in relation to institutional changes in the use of intrapartum antibiotic prophylaxis. METHODS A retrospective review of data for all infants with E. coli sepsis at Yale-New Haven Hospital from 1979 to 2006 was performed. Study periods were based on predominant intrapartum antibiotic prophylaxis practices at Yale-New Haven Hospital, that is, (1) 1979 to 1992 (no formal intrapartum antibiotic prophylaxis), (2) 1993 to 1996 (risk factor-based), and (3) 1997 to 2006 (screening-based). Sepsis rates and patterns of ampicillin resistance were compared. RESULTS Fifty-three cases of E. coli early-onset sepsis and 129 cases of E. coli late-onset sepsis were identified over 3 eras. In very low birth weight (<1500 g) infants, increases in E. coli early-onset sepsis (period 1: 2.83 cases per 1000 very low birth weight admissions; period 2: 7.12 cases per 1000 very low birth weight admissions; period 3: 10.22 cases per 1000 very low birth weight admissions), intrapartum ampicillin exposure, and ampicillin-resistant E. coli were observed. Intrapartum ampicillin exposure was determined to be an independent risk factor for ampicillin-resistant E. coli early-onset sepsis. For the first time, a significant increase in E. coli late-onset sepsis was observed in preterm infants (period 1: 10.39 cases per 1000 very low birth weight admissions; period 2: 16.01 cases per 1000 very low birth weight admissions; period 3: 21.66 cases per 1000 very low birth weight admissions) and term infants (period 1: 4.07 cases per 1000 admissions; period 2: 4.22 cases per 1000 admissions; period 3: 8.23 cases per 1000 admissions). CONCLUSIONS Studies to provide a better understanding of potential consequences of intrapartum antibiotic exposure and its contribution to evolving trends in neonatal sepsis are urgently needed.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520-8064, USA
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Steiner LA, Bizzarro MJ, Ehrenkranz RA, Gallagher PG. A decline in the frequency of neonatal exchange transfusions and its effect on exchange-related morbidity and mortality. Pediatrics 2007; 120:27-32. [PMID: 17606558 DOI: 10.1542/peds.2006-2910] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to identify trends in patient demographics and indications for and complications related to neonatal exchange transfusion over a 21-year period in a single institution using a uniform protocol for performing the procedure. METHODS A retrospective chart review of 107 patients who underwent 141 single- or double-volume exchange transfusions from 1986-2006 was performed. Patients were stratified into 2 groups, 1986-1995 and 1996-2006, on the basis of changes in clinical practice influenced by American Academy of Pediatrics management guidelines for hyperbilirubinemia. RESULTS There was a marked decline in the frequency of exchange transfusions per 1000 newborn special care unit admissions over the 21-year study period. Patient demographics and indications for exchange transfusion were similar between groups. A significantly higher proportion of patients in the second time period received intravenous immunoglobulin before exchange transfusion. There was a higher proportion of patients in the 1996-2006 group with a serious underlying condition at the time of exchange transfusion. During that same time period, a lower proportion of patients experienced an adverse event related to the exchange transfusion. Although a similar percentage of patients in both groups experienced hypocalcemia and thrombocytopenia after exchange transfusion, patients treated from 1996-2006 were significantly more likely to receive calcium replacement or platelet transfusion. No deaths were related to exchange transfusion in either time period. CONCLUSIONS Improvements in prenatal and postnatal care have led to a sharp decline in the number of exchange transfusions performed. This decline has not led to an increase in complications despite relative inexperience with the procedure.
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Affiliation(s)
- Laurie A Steiner
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064, USA
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Abstract
AIM To measure circulating CD34+ cell levels in premature neonates and to correlate the initial CD34+ counts with measures of pulmonary function and neonatal morbidity. METHODS CD34+ cell counts were measured in the peripheral blood of preterm neonates (gestational ages 24-32 weeks) ventilated for respiratory disease at <48 h of life, and at the start of the 2nd, 3rd and 4th weeks of life. Data pertaining to neonatal demographics and short-term outcomes were collected. Pulmonary function tests were performed to coincide with CD34+ sampling. RESULTS Thirty preterm neonates with median gestational age of 24 weeks and birth weight of 641 g were analysed. A mean of 99.4 CD34+ cells per microliter was observed in the 1st week of life with a decline to 54.4 cells per microliter by the 4th week. An inverse correlation between initial CD34+ count and gestational age (p=0.01) was observed. No significant correlations were observed with measures of pulmonary function or neonatal morbidities. CONCLUSIONS Extremely premature neonates have remarkably high levels of CD34+ cells in their peripheral blood at birth. Umbilical cord blood from this population may potentially provide an abundant source of hematopoietic stem and progenitor cells for therapeutic purposes.
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Division of Perinatal Medicine, Yale University School of Medicine, New Haven, CT 06520-8064, USA.
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Bizzarro MJ, Dembry LM, Baltimore RS, Gallagher PG. Case-control analysis of endemic Serratia marcescens bacteremia in a neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2007; 92:F120-6. [PMID: 17088342 PMCID: PMC2675455 DOI: 10.1136/adc.2006.102855] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Serratia marcescens is an opportunistic gram-negative rod which typically infects compromised hosts. OBJECTIVES To identify risk factors, signs, and outcomes associated with non-epidemic S marcescens bacteremia in a neonatal intensive care unit (NICU). METHODS The records of infants with S marcescens bacteremia while in the Yale-New Haven Hospital NICU from 1980-2004 were reviewed. A matched case-control study was performed by comparing each case of S marcescens to 2 uninfected controls and 2 cases of Escherichia coli bacteremia. RESULTS Twenty-five sporadic cases of S marcescens bacteremia were identified. Eleven available isolates were determined to be different strains by pulse field gel electrophoresis. Infants with S marcescens bacteremia had median gestational age and birth weight of 28 weeks and 1235 grams, respectively. Compared to matched, uninfected controls, infants with S marcescens bacteremia were more likely to have had a central vascular catheter (OR = 4.33; 95% CI (1.41 to 13.36)) and surgery (OR = 5.67; 95% CI (1.81 to 17.37)), and had a higher overall mortality (44% vs 2%; OR = 38.50; 95% CI (4.57 to 324.47)). Compared to E coli matched controls, infants with S marcescens bacteremia had later onset of infection (median of 33 days of life vs 10; p<0.001), prolonged intubation (OR = 5.76; 95% CI (1.80 to 18.42)), and a higher rate of CVC (OR = 7.77; 95% CI (2.48 to 24.31)) use at the time of infection. A higher rate of meningitis (24% vs 7%; OR = 3.98; 95% CI (1.09 to 14.50)) was observed with S marcescens bacteremia compared to E coli. CONCLUSIONS S marcescens bacteremia occurs sporadically in the NICU, primarily in premature infants requiring support apparatus late in their hospital course. Associated meningitis is common and mortality high.
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Affiliation(s)
- Matthew J Bizzarro
- Divisions of Perinatal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8064, USA
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Abstract
Neonates, particularly those born prematurely, are at an increased risk of bacterial infection. Empiric treatment with antimicrobials occurs frequently in the neonatal intensive care unit (NICU). Repeated and/or prolonged courses of antibiotic exposure have resulted in an increase in the prevalence of hospital-acquired, antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and multidrug-resistant Gram-negative rods. As bacterial strains become increasingly resistant to standard antimicrobial therapy, measures to control and prevent this problem are essential. Current efforts have focused on monitoring and restricting the use of antimicrobials, proper hand hygiene, evaluation of potential reservoirs of bacterial acquisition and transmission, cohorting and isolation of colonized infants, decolonization strategies, and fostering of effective inter- and intrahospital communication.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Abstract
OBJECTIVES The goals were to isolate and to estimate the genetic susceptibility to retinopathy of prematurity. METHODS A retrospective study (1994-2004) from 3 centers was performed with zygosity data for premature twins who were born at a gestational age of < or = 32 weeks and survived beyond a postmenstrual age of 36 weeks. Retinopathy of prematurity was diagnosed and staged by pediatric ophthalmologists at each center. Data analyses were performed with mixed-effects logistic regression analysis and latent variable probit modeling. RESULTS A total of 63 monozygotic and 137 dizygotic twin pairs were identified and analyzed. Data on gestational age, birth weight, gender, respiratory distress syndrome, retinopathy of prematurity, bronchopulmonary dysplasia, duration of ventilation and supplemental oxygen use, and length of stay were comparable between monozygotic and dizygotic twins. In the mixed-effects logistic regression analysis for retinopathy of prematurity, gestational age and duration of supplemental oxygen use were significant covariates. After controlling for known and unknown nongenetic factors, genetic factors accounted for 70.1% of the variance in liability for retinopathy of prematurity. CONCLUSION In addition to prematurity and environmental factors, there is a strong genetic predisposition to retinopathy of prematurity.
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520-8064, USA
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Bhandari V, Bizzarro MJ, Shetty A, Zhong X, Page GP, Zhang H, Ment LR, Gruen JR. Familial and genetic susceptibility to major neonatal morbidities in preterm twins. Pediatrics 2006; 117:1901-6. [PMID: 16740829 DOI: 10.1542/peds.2005-1414] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia remain significant causes of morbidity and mortality in preterm newborns. OBJECTIVES Our goal was to assess the familial and genetic susceptibility to intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia. METHODS Mixed-effects logistic-regression and latent variable probit model analysis were used to assess the contribution of several covariates in a multicenter retrospective study of 450 twin pairs born at < or =32 weeks of gestation. To determine the genetic contribution, concordance rates in a subset of 252 monozygotic and dizygotic twin pairs were compared. RESULTS The study population had a mean gestational age of 29 weeks and birth weight of 1286 g. After controlling for effects of covariates, the twin data showed that 41.3%, 51.9%, and 65.2%, respectively, of the variances in liability for intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia could be accounted for by genetic and shared environmental factors. Among the 63 monozygotic twin pairs, the observed concordance for bronchopulmonary dysplasia was significantly higher than the expected concordance; 12 of 18 monozygotic twin pairs with > or =1 affected member had both members affected versus 3.69 expected. After controlling for covariates, genetic factors accounted for 53% of the variance in liability for bronchopulmonary dysplasia. CONCLUSIONS Twin analyses show that intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia are familial in origin. These data demonstrate, for the first time, the significant genetic susceptibility for bronchopulmonary dysplasia in preterm infants.
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Affiliation(s)
- Vineet Bhandari
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Abstract
OBJECTIVE Yale-New Haven Hospital (Y-NHH) has maintained the longest running, single-center longitudinal database of neonatal sepsis, started in 1928. The objective of this study was to update this database with review of neonatal sepsis cases at Y-NHH to identify longitudinal trends in demographics, pathogens, and outcome. METHODS Records of infants with positive blood cultures obtained while they were inpatients in the NICU at Y-NHH from 1989 to 2003 were reviewed retrospectively. Records of infants who were < or =30 days of age, had positive blood cultures, and were hospitalized at Y-NHH outside the NICU from the same period were also reviewed, and all findings were compared with 60 years of preexisting data. RESULTS A total of 862 organisms were identified in 755 episodes of sepsis from 647 infants. The percentage of cases of early-onset sepsis decreased and late-onset sepsis increased compared with the previous 10-year study period. A marked increase in cases as a result of commensal species was observed, particularly in preterm infants who had indwelling central vascular catheters, were receiving parenteral nutrition, and required prolonged mechanical ventilation. The overall percentage of sepsis caused by group B streptococcus and Escherichia coli decreased. No episodes of sepsis from Streptococcus pneumoniae or S pyogenes, common in the early years of the survey, were observed. The sepsis-related mortality rate steadily decreased, from 87% in 1928 to 3% in 2003. CONCLUSIONS The demographics, pathogens, and outcome associated with neonatal sepsis continue to change. The increase in late-onset sepsis in preterm infants who required prolonged intensive care indicates that strategies to prevent infection are urgently needed for this population of infants.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Yale University School of Medicine, New Haven, CT 06520-8064, USA
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Abstract
Endogenous hormones, such as glucocorticoids, play a major role in the development of the fetal lung. Considerable effort has been devoted to defining the underlying physiology and the clinical effects of administration of antenatal glucocorticoids to women who are at risk of premature delivery. Antenatal glucocorticoids have significant therapeutic benefits to the neonate with respect to the respiratory distress syndrome, intraventricular hemorrhage, and mortality. Current controversies relate to the choice of glucocorticoid, optimal dosing regime, number of courses of therapy that should be administered, and, most importantly, potential toxicities.
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Affiliation(s)
- Matthew J Bizzarro
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, Children's Hospital WP 493, 333 Cedar Street, P.O. Box 208064, New Haven, CT 06520-8064, USA
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Abstract
Neonatal anemia is a condition with a diverse etiologic spectrum.Therefore, in order to form a focused differential diagnosis, it is important for the caregiver to have some knowledge of the more common causes of low hemoglobin and hematocrit concentrations in the neonate. Proper history taking, physical examination, and interpretation of diagnostic tests can narrow this focus and aid in establishing an accurate diagnosis and in directing the appropriate therapeutic interventions.
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MESH Headings
- Algorithms
- Anemia/diagnosis
- Anemia/epidemiology
- Anemia/etiology
- Anemia/therapy
- Anemia, Hemolytic, Congenital/diagnosis
- Anemia, Hemolytic, Congenital/epidemiology
- Anemia, Hemolytic, Congenital/therapy
- Anemia, Hypoplastic, Congenital/diagnosis
- Anemia, Hypoplastic, Congenital/epidemiology
- Anemia, Hypoplastic, Congenital/therapy
- Diagnosis, Differential
- Erythrocyte Transfusion
- Humans
- Infant, Newborn
- Iron/therapeutic use
- Reference Values
- United States/epidemiology
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Affiliation(s)
- Matthew J Bizzarro
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208064, New Haven, CT 06520-8064, USA
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