The challenges of neonatal sepsis management

OBJECTIVES

To present current evidence on the etiology, risk factors, diagnosis, and management of early and late neonatal sepsis.

SOURCE OF DATA

Non-systematic review of the Medline (PubMed), Scopus, Web of Science, Cochrane, and Google Scholar databases regarding the following terms: neonatal sepsis, early neonatal sepsis, late neonatal sepsis, empirical antibiotic therapy, sepsis calculator, vancomycin, newborn, preterm newborn.

DATA SYNTHESIS

Neonatal sepsis is a frequent cause of neonatal morbidity and mortality. Its diagnosis is difficult. Continuous observation of the patient is critical to diagnostic suspicion. When neonatal sepsis is suspected, bacteriological tests should be collected. Vancomycin should not be routinely using in the empirical antibiotic regimen in late neonatal sepsis, and the main protective mechanisms against neonatal sepsis are handwashing and the use of breast milk.

CONCLUSIONS

Newborns constitute a group that is more vulnerable to sepsis. Knowledge of risk factors and etiological agents allows a better approach to the newborn with sepsis.

Experimental study of the application of a new bone cement loaded with broad spectrum antibiotics for the treatment of bone infection

OBJECTIVES

To evaluate the in vivo behaviour of a new bone cement loaded with antibiotics, in a rabbit bone infection model.

MATERIAL AND METHODS

Sixteen New Zealand rabbits divided into 4 groups were used, depending on the cement (commercial or experimental) and the antibiotic (vancomycin or linezolid) used to control a bone infection caused by Staphylococcus aureus. The commercial cement is Palacos^® R and the experimental cement has been achieved by adding PLGA to the solid phase of Palacos^® R cement. A novel histological staging method based on bone histoarchitecture has been used. This staging allows us a global vision of bone repair capacity, in the presence of modified cement, and also allows us to correlate the damage generated with the functionality of the tissue.

RESULTS

The degree of bone destructuration found depended on the type of cement and antibiotic, and was higher in the groups with commercial cement than in the experimental group (P<.01) and in the groups with linezolid with respect to vancomycin (P=.04) The percentage of macrophages varied exclusively depending on the antibiotic used, and was higher in the vancomycin groups (P=.04).

DISCUSSION

The development of new formulations of bone cement that release more, and more prolonged, new generation antibiotics such as linezolid, present an in vivo behaviour superior to commercial cement, respecting the bone structure. This behaviour would have a clinical implication in fighting infections by increasingly resistant germs in the treatment of prosthetic infection.

Combined effect of bacteriocin produced by Lactobacillus plantarum ST8SH and vancomycin, propolis or EDTA for controlling biofilm development by Listeria monocytogenes

The Listeria monocytogenes strains selected in the present study exhibited similar behavior in biofilm formation, independently of the tested conditions (bacteriocin from L. plantarum ST8SH, vancomycin, propolis (a natural antimicrobial product) and EDTA (chelating agent)), individual or in associations. The individual application of vancomycin had better inhibitory activity than that of propolis and EDTA; however, the association of the previously mentioned antimicrobial agents with bacteriocins resulted in better performance. However, when we compared the effects of vancomycin, propolis and EDTA, we could clearly observe that the combined application of bacteriocin and vancomycin was more effective than the combination of bacteriocin and propolis, and bacteriocin and EDTA. Considering the current need to reduce the use of antimicrobials and chemical substances in food processing, propolis can represent an alternative to improve the inhibitory effect of bacteriocins against L. monocytogenes biofilm formation, based on the obtained results. In general, high concentrations of bacteriocin produced by L. plantarum ST8SH were more effective in biofilm inhibition, and similar results were observed for vancomycin and propolis; however, all tested EDTA concentrations had similar effect on biofilm formation.

Vancomycin added to the wash solution of the cell-saver. Effect on bacterial contamination

OBJECTIVES

The aim of this study is to test whether the addition of a low-dose of antibiotic (vancomycin) to the wash solution (saline) of the cell-saver reduces the incidence of bacterial contamination of the autologous red blood cell (RBCs) concentrate recovered.

MATERIAL AND METHOD

Experimental, randomized, double-blind, parallel group study performed on 20 consecutive patients scheduled for posterior spinal fusion surgery. Intraoperative bleeding was processed through a cell-saver: HaemoLite^® 2+, in which the RBCs were washed according to randomization group, with saline (control group) or saline+10μg/ml^-1 vancomycin (vanco group). Data regarding age, weight, processed and recovered volume, blood count, blood culture, and vancomycin concentration in RBCs concentrates obtained and incidence of fever after reinfusion were collected.

RESULTS

Processed volume was 843±403ml and recovered volume 121±29ml, with haemoglobin concentration 10.4±5.0g/dl^-1 and haematocrit 29.1±15.9% (mean±SD). Recovered RBC concentrate cultures were positive for coagulase-negative Staphylococcus in 5 cases (50%) of the control group while all cultures were negative in the vanco group (P=.016). The difference between the theoretical concentration of vancomycin administered and the concentration determined in the recovered RBC concentrate was 1.31μg/ml^-1 (95% CI 1.19 to 1.43; P=.074).

CONCLUSIONS

The addition of vancomycin at a concentration of 10ug/ml^-1 to the wash solution of the cell-saver achieved similar concentrations in the autologous blood concentrate recovered allowing for bacterial removal, with negative blood cultures in all cases.

Endophthalmitis after intravitreal injections. Incidence, management and prognosis

OBJECTIVE

To assess the rate of endophthalmitis after intravitreal injection (IVI) in a «clean room» of a single health centre, following the guidelines of the Spanish Vitreo-Retinal Society (SERV). An analysis was performed on the culture specimens, response to treatment, and final outcomes (guidelines).

MATERIAL AND METHODS

A retrospective, observational study was conducted on a consecutive case series of patients diagnosed with infectious endophthalmitis after IVI in a single health centre between 2010 and 2015. Intravitreal and systemic treatment was given following the SERV guidelines. The patients were followed up the case was resolved.

RESULTS

There were 5 cases of endophthalmitis out of 9467 IVI (incidence 0.053%). Positive cultures were obtained in aqueous and/or vitreous fluid in all cases, with Staphylococcus epidermidis being involved in 4 out of 5 cases. In 2 cases, final visual acuity was non-light perception due to intractable retinal detachments after resolution of the infectious process.

CONCLUSIONS

IVI performed in a «clean room» have a low incidence of endophthalmitis. The most common infectious agent was Staphylococcus species. In 2 cases the functional prognosis was poor.

Empirical antimicrobial therapy for late-onset sepsis in a neonatal unit with high prevalence of coagulase-negative Staphylococcus

OBJECTIVE

The aim of this study was to compare two different empiric treatments for late-onset neonatal sepsis, vancomycin and oxacillin, in a neonatal intensive care unit with a high prevalence of coagulase-negative Staphylococcus.

METHODS

A cross-sectional study was conducted in an neonatal intensive care unit from 2011 to 2014. Data from the medical records of at-risk newborns were collected daily. Infections were defined according to the National Health Surveillance Agency criteria. Data analysis was performed using an internal program.

RESULTS

There was a significant reduction in the number of Staphylococcus aureus infections (p=0.008), without endocarditis, meningitis, or lower respiratory tract infection, as well as a reduction in the frequency of deaths related to S. aureus infection. There were no significant changes in the incidence of Gram-negative bacterial or fungal infections. An increase in coagulase-negative Staphylococcus infections was observed (p=0.022). However, there was no measured increase in related morbidity and mortality. There was a reduction in the median number of days of treatment with oxacillin from 11.5 to 6 days (p<0.001) and an increase of one day in the median number of days of treatment with vancomycin (p=0.046).

CONCLUSIONS

Modification of the empiric treatment regimen for neonatal late-onset sepsis with use of oxacillin showed a significant reduction in S. aureus infections, as well as a reduction in the frequency of infections with major organ system involvement and mortality due to infection with this microorganism. As a result, oxacillin can be considered as an effective treatment for late-onset sepsis, making it possible to avoid broad-spectrum antibiotics.

Vancomycin heteroresistant community associated methicillin-resistant Staphylococcus aureus ST72-SCCmecIVa strain colonizing the nostrils of a five-year-old Spanish girl

BACKGROUND AND OBJECTIVES

During a community methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization study, an MRSA strain with vancomycin hetero-resistance (h-VISA) was isolated from a five year-old girl with tetralogy of Fallot without previous exposure to vancomycin. An extended nasal colonization study was performed on all her close relatives.

RESULTS

Only the patient and her sister were colonized by an h-VISA MRSA strain (clone USA 700, ST72, t148, agr 1 and SCCmec IVa). Mupirocin decolonisation was effective in the elder sister. A new nasal decolonisation in the younger girl using fusidic acid was also successful. However, after decolonisation both sisters were colonized by a methicillin-susceptible S. aureus (ST30, t012 and agr 3) previously isolated from their mother's nostrils.

CONCLUSION

As S. aureus have a great capacity to spread among people in close contact, knowledge of a patients' colonization status, tracing contacts, and a correct management are critical issues for the successful containment of multiresistant staphylococci.

[Application of vancomycin powder into the wound during spine surgery: systematic review and meta-analysis]

OBJECTIVE

To determine the effects of applying vancomycin powder within the surgical wound on the risk of surgical infections, pseudo-arthrosis and adverse events, in patients undergoing spinal surgery.

MATERIAL AND METHODS

A meta-analysis was carried out, including controlled studies that evaluated the risk of postoperative infections and/or pseudo-arthrosis in patients undergoing spinal surgery in which vancomycin powder was applied within the surgical wound.

RESULTS

were presented as pooled relative risks, with its 95% confidence intervals. Additionally, the frequency of complications attributable to vancomycin was also assessed.

RESULTS

A total of six controlled studies (3,379 subjects) were included. Pooled relative risks were: surgical site infection, 0.11 (95%CI: 0.05-0.25; P<.00001), and pseudo-arthrosis, 0.87 (95%CI; 0.34-2.21; P=.77). No statistically significant heterogeneity was found in both analyses. In 1,437 patients treated with vancomycin, there were no recorded vancomycin-related adverse events.

CONCLUSIONS

Application of vancomycin powder into the wound was associated with a significantly reduced risk of surgical site infections, without increasing pseudo-arthrosis or adverse events. However, randomized controlled trials are needed, in order to confirm the present results and make recommendations with more certainty.

[Clinical features and outcome of community-acquired methicillin-resistant Staphylococcus aureus pneumonia]

INTRODUCTION

The aim of this study is to describe the epidemiological and clinical features, treatment and prognosis of community-acquired pneumonia (CAP) caused by methicillin-resistant Staphylococcus aureus (MRSA) in two different geographic regions where community-acquired MRSA (CA-MRSA) infections have different frequencies.

METHODS

Observational study of patients admitted to two hospitals (one in Argentina, the other in Spain) between March 2008 and June 2012.

RESULTS

We documented 16 cases of CAP caused by MRSA. MRSA accounted for 15 of 547 (2.7%) cases of CAP in Hospital Rodolfo Rossi and 1 of 1258 (0,08%) cases at the Hospital Universitari de Bellvitge (P ≤ .001). Most patients were young and previously healthy. Multilobar infiltrates, cavitation and skin and soft tissue involvement were frequent. All patients had positive blood cultures. Five patients required admission to the intensive care unit. Early mortality (≤ 48 hours) was 19%, and overall mortality (≤ 30 days) was 25%.

CONCLUSION

CAP caused by MRSA causes high morbidity and mortality rates. It should be suspected in areas with a high prevalence of CA-MRSA infections, and especially in young and healthy patients who present with multilobar pneumonia with cavitation. Mortality is mainly related to septic shock and respiratory failure and occurs early in most cases.