Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS)

BACKGROUND

There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design.

METHODS AND FINDINGS

Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability.

CONCLUSION

Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis.

TRIAL REGISTRATION

ClinicalTrials.gov, (NCT03721302).

Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam

Objective: Data on the management and outcomes of acute myocarditis treated with extracorporeal membrane oxygenation (ECMO) among low- and middle-income countries are limited. This study aimed to determine the short-term outcomes and also identify factors associated with ECMO use among children with acute myocarditis at a tertiary children's hospital in Vietnam. Methods: A single-center, retrospective observational study was conducted between January 2016 and February 2021. Pediatric patients with acute myocarditis, aged 1 month to 16 years, were included. Results: In total, 54 patients (male, 46%; median age, 7 years) with acute myocarditis were included; 37 of them received ECMO support. Thirty percent (16/54) of the patients died, and 12 of them received ECMO. Laboratory variables that differed between survivors and non-survivors included median left ventricular ejection fraction (LVEF) at 48 h (42 vs. 25%; p = 0.001), platelet count (304 g/L [interquartile range (IQR): 243-271] vs. 219 g/L [IQR: 167-297]; p = 0.014), and protein (60 g/dl [IQR: 54-69] vs. 55 [IQR: 50-58]; p = 0.025). Among patients who received ECMO, compared with the survivors, non-survivors had a low LVEF at 48 h (odds ratio (OR), 0.8; 95% confidence interval (CI): 0.6-0.9; p = 0.006) and high vasoactive-inotropic score (OR, 1.0; 95% CI: 1.0-1.0; p = 0.038) and lactate (OR, 2.8; 95% CI, 1.2-6.1; p = 0.013) at 24 h post-ECMO. Conclusions: The case fatality rate among children with acute myocarditis was 30 and 32% among patients requiring ECMO support. Arrhythmia was an indicator for ECMO in patients with cardiogenic shock.

Pertussis Infants Needing Mechanical Ventilation and Extracorporeal Membrane Oxygenation: Single-Center Retrospective Series in Vietnam

OBJECTIVES

Pertussis is an infectious disease that causes epidemics and outbreaks and is associated with a high mortality rate, especially in infants, in both developed and developing countries. We aimed to characterize infants with pertussis with respiratory failure and shock and investigated the factors related to mortality.

DESIGN

A retrospective, observational study conducted between January 2015 and October 2020.

SETTING

This study was conducted at the Vietnam National Children's Hospital, which is a government hospital that serves as a tertiary care center in Hanoi, Vietnam.

PATIENTS

Children who fulfilled the following inclusion criteria were included: 1) admitted to the PICU, 2) less than 16 years old, 3) pertussis confirmed by real-time polymerase chain reaction, and 4) treated with mechanical ventilation due to respiratory failure and shock.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Seventy-three mechanically ventilated children (40 boys; median age, 56 d), whereas 19 patients received extracorporeal membrane oxygenation support. Twenty-six patients (36%) died including 12 who received extracorporeal membrane oxygenation. Those who received extracorporeal membrane oxygenation support had higher leukocyte counts upon admission and were more frequently diagnosed with pulmonary hypertension and stage 3 acute kidney injury. Compared with survivors, nonsurvivors showed increased heart rates, leukocyte and neutrophil counts, and lower systolic and diastolic blood pressure at admission. Increased Vasoactive-Inotropic Score, stage 3 acute kidney injury, fluid overload, the use of renal replacement therapy, and extracorporeal membrane oxygenation use were prevalent among nonsurvivors.

CONCLUSIONS

In this study, around one third of mechanically ventilated patients with pertussis died. Those who received extracorporeal membrane oxygenation had higher leukocyte counts, a higher prevalence of pulmonary hypertension, and advanced stages of acute kidney injury. Higher Vasoactive-Inotropic Score and advanced stages of acute kidney injury were associated with a greater risk of mortality.

In vitro inhibition of food spoilage and foodborne pathogenic bacteria by essential oil and leaf extracts of Magnolia liliflora Desr

The aim of this study was to examine the chemical composition of the essential oil isolated from the floral parts of Magnolia liliflora Desr. by hydrodistillation, and to test the efficacy of essential oil and various leaf extracts against a diverse range of microorganisms comprising food spoilage and foodborne pathogenic bacteria. The chemical composition of essential oil was analyzed by GC-MS. It was determined that 52 compounds, which represented 78.07% of total oil, were present in the oil. The oil contained mainly levoxine (15.59%), methylcyclopropane (24.26%), 2-beta-pinene (5.3%), caryophyllene oxide (4.01%), and beta-caryophyllene (1.7%). The oil (1000 ppm/disc) and leaf extracts (1500 ppm/disc) exhibited promising antibacterial effects against the tested pathogens as a diameter of zones of inhibition (9 to 18 and 7 to 12 mm) and MIC values (125 to 1000 and 500 to 3000 microg/mL), respectively. Also, the oil had a potent detrimental effect on the viable count of the tested bacteria. The results obtained in this study support the role of essential oil and the leaf extracts derived from M. liliflora as a remarkable approach to inhibit the growth of food spoilage and foodborne pathogens.

The effect of Trypanosoma evansi infection on pig performance and vaccination against classical swine fever

Although Trypanosoma evansi is not considered as an important pathogen in pigs, it may interfere with other pathogens or vaccinations by its immunosuppressive nature. In order to determine whether T. evansi alters pig performance and induces immunosuppression in pigs, induction of immune responses by vaccination against classical swine fever (CSF) and by immunization with a control antigen, human serum albumin (HSA), was assessed in T. evansi-infected and non-infected animals. Although T. evansi infection did not have a significant influence on growth performance, feed conversion or PCV, antibody responses against both the test antigen HSA and the CSF vaccine were significantly reduced in T. evansi-infected animals as compared to uninfected animals. Moreover, the reduced response against the CSF vaccine appears to be accompanied by a less well-developed protection against CSF with higher fever responses and leukopenia. This immunosuppression might explain the accounts of poor protection of CSF-vaccinated pigs reported in T. evansi-endemic areas of Vietnam, and suggests that prior treatments with trypanocidal drugs to improve the efficacy of CSF vaccination, may be justified.

First cases of disseminated penicilliosis marneffei infection among patients with acquired immunodeficiency syndrome in Vietnam

To our knowledge, this is the first report of penicilliosis marneffei among patients with acquired immunodeficiency syndrome (AIDS) in Vietnam. The 4 patients we studied were from Ho Chi Minh City and the provinces of Tay Ninh, Dong Nai, and Kon Tum. In 2 patients, the infections were fatal.

Management of multiple drug-resistant malaria in Viet Nam

Malaria is still the most common infectious cause of mortality and morbidity in Viet Nam as it is in many developing countries in the tropics. The presence of resistance to available antimalarials and compliance in the target population are factors that influence the choice of drugs and regimens. In order to develop an ideal treatment for malaria, we conducted several clinical trials in patients with the disease in different settings. The results of these trials suggest that a combination of single dose artemisinin (or its derivatives) and mefloquine is the most effective, safe and practical treatment for acute non-complicated malaria due to multidrug-resistant Plasmodium falciparum. Concerning severe and complicated malaria, parenteral or rectal multi-doses of artemisinin or analogues are recommended due to their rapid parasite clearance time and other possible anti-cytoadherence effects. With its rapid parasite clearance, very early treatment of uncomplicated cases with artemisinin (and derivatives), especially at a health post level may help to prevent the development of complications, consequently reducing the number of severe cases and the malaria mortality rate.

An open randomized comparison of intravenous and intramuscular artesunate in severe falciparum malaria

An open paired randomized comparison of intramuscular and intravenous artesunate was conducted in 28 adult patients with severe falciparum malaria. The dose regimen in both groups was 2 mg/kg given immediately followed by 1 mg/kg at 12 and 24 h, and then daily until the patient could swallow. Both routes of administration were well tolerated and there was no evidence of toxicity. One patient in each treatment group died. Clinical and parasitological measures of recovery in survivors were similar in the 2 groups with mean fever clearance times of 37.3 h (standard deviation [SD] = 26.1 h) and 31.5 h (SD = 24.2 h) and mean parasite clearance times of 33.4 h (SD = 13.9 h) and 29.4 h (SD = 12.7 h) in the intravenous and intramuscular groups respectively. Artesunate is equally effective and well tolerated when given by the intravenous or intramuscular routes.

Effects of adrenaline pretreatment on in vitro binding of 125I-triiodothyronine to nuclear receptor, intracellular distribution of endogenous triiodothyronine and activities of alfa-glycerophosphate dehydrogenase and malic enzyme in rat liver

Especially coated adrenaline tablets (A) or placebo tablets (P) which release linearly the hormone were implanted in male Wistar rats. Six hours later animals were sacrificed and kinetic parameters of T3-125I binding to nuclear receptor, intracellular distribution of endogenous T3 and activities of alfa-GPD and ME were investigated. The association constant values (Ka) of nuclear receptor were increased after pretreatment with 7.5, 15 and 45 mg A tablets and were 1.07, 1.35 and 1.48 X 10(9) M-1 vs 0.85 X 10(8) M-1 value seen after P. The maximal binding capacity (MBC) values decreased after pretreatment with the same doses of A and were 0.044, 0.036 and 0.025 pmol T3/100 micrograms DNA vs. 0.065 pmol T3/100 micrograms DNA in P pretreated. Adrenaline pretreatment significantly increased the amount of endogenous T3 present in liver nuclei while the amount of T3 present in cytosol decreased. Activity of mitochondrial alfa-GPD was increased after 15 and 45 mg of A. Significant rise of activity of cytosol ME was seen only after pretreatment with 45 mg of A.