Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study

BACKGROUND

Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX.

METHODS

The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording.

RESULTS

Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%).

CONCLUSIONS

Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.

Evidence for contamination as the origin for bacteria found in human placenta rather than a microbiota

Until recently the in utero environment of pregnant women was considered sterile. Recent high-sensitivity molecular techniques and high-throughput sequencing lead to some evidence for a low-biomass microbiome associated with the healthy placenta. Other studies failed to reveal evidence for a consistent presence of bacteria using either culture or molecular based techniques. Comparing conflicting “placental microbiome” studies is complicated by the use of varied and inconsistent protocols. Given this situation, we undertook an evaluation of the in utero environment sterility using several controlled methods, in the same study, to evaluate the presence or absence of bacteria and to explain contradictions present in the literature. Healthy pregnant women (n = 38) were recruited in three maternity wards. Placenta were collected after cesarean section with or without Alexis^® and vaginal delivery births. For this study we sampled fetal membranes, umbilical cord and chorionic villi. Bacterial presence was analyzed using bacterial culture and qPCR on 34 fetal membranes, umbilical cord and chorionic villi samples. Shotgun metagenomics was performed on seven chorionic villi samples. We showed that the isolation of meaningful quantities of viable bacteria or bacterial DNA was possible only outside the placenta (fetal membranes and umbilical cords) highlighting the importance of sampling methods in studying the in utero environment. Bacterial communities described by metagenomics analysis were similar in chorionic villi samples and in negative controls and were dependent on the database chosen for the analysis. We conclude that the placenta does not harbor a specific, consistent and functional microbiota.

Detection of microbial cell-free DNA in maternal and umbilical cord plasma in patients with chorioamnionitis using next generation sequencing

Background

Chorioamnionitis has been linked to spontaneous preterm labor and complications such as neonatal sepsis. We hypothesized that microbial cell-free (cf) DNA would be detectable in maternal plasma in patients with chorioamnionitis and could be the basis for a non-invasive method to detect fetal exposure to microorganisms.

Objective

The purpose of this study was to determine whether next generation sequencing could detect microbial cfDNA in maternal plasma in patients with chorioamnionitis.

Study design

Maternal plasma (n = 94) and umbilical cord plasma (n = 120) were collected during delivery at gestational age 28–41 weeks. cfDNA was extracted and sequenced. Umbilical cord plasma samples with evidence of contamination were excluded. The prevalence of microorganisms previously implicated in choriomanionitis, neonatal sepsis and intra-amniotic infections, as described in the literature, were examined to determine if there was enrichment of these microorganisms in this cohort. Specific microbial cfDNA associated with chorioamnionitis was first detected in umbilical cord plasma and confirmed in the matched maternal plasma samples (n = 77 matched pairs) among 14 cases of histologically confirmed chorioamnionitis and one case of clinical chorioamnionitis; 63 paired samples were used as controls. A correlation of rank of a given microorganism across maternal plasma and matched umbilical cord plasma was used to assess whether signals found in umbilical cord plasma were also present in maternal plasma.

Results

Microbial DNA sequences associated with clinical and/or histological chorioamnionitis were enriched in maternal plasma in cases with suspected chorioamnionitis when compared to controls (12/14 microorganisms, p = 0.02). Analysis of the microbial cfDNA in umbilical cord plasma among the 1,251 microorganisms detectable with this assay identified Streptococcus mitis, Ureaplasma spp., and Mycoplasma spp. in cases of suspected chorioamnionitis. This assay also detected cfDNA from Lactobacillus spp. in controls. Comparison between maternal plasma and umbilical cord plasma confirmed these signatures were also present in maternal plasma. Unbiased analysis of microorganisms with significantly correlated signal between matched maternal plasma and umbilical cord plasma identified the above listed 3 microorganisms, all of which have previously been implicated in patients with chorioamnionitis (Mycoplasma hominis p = 0.0001; Ureaplasma parvum p = 0.002; Streptococcus mitis p = 0.007). These data show that the pathogen signal relevant for chorioamnionitis can be identified in both maternal and umbilical cord plasma.

Conclusion

This is the first report showing the detection of relevant microbial cell-free cfDNA in maternal plasma and umbilical cord plasma in patients with clinical and/or histological chorioamnionitis. These results may lead to the development of a specific assay to detect perinatal infections for targeted therapy to reduce early neonatal sepsis complications.

Umbilical Diphtheria: Resurgence of a Forgotten Entity

Diphtheria has had a resurgence in India over the past decade. We present a case of umbilical diphtheria in a neonate, who had a good outcome with administration of anti-toxin and antibiotics.

Prevalence, Morphology, Embryogenesis, and Diagnostic Utility of Umbilical Cord Vitelline Vascular Remnants

The objective of this study is to better understand embryonic vitelline vascular remnants in the umbilical cord, to assess their prevalence, to categorize their morphology, and then finally to describe and assess inflammation arising from these structures. During routine placental sign out, the author noted the presence or absence of vitelline vessel remnants for 1 year; when present, he assessed their histologic patterns and noted whether there were neutrophils marginating from the remnants and into the adjacent Wharton's jelly and whether there was any other evidence of amniotic fluid infection in sections of placental disc, membranes, or cord. All cord sections with vitelline vessel remnants were immunostained for CD15 to document any infiltrates, to highlight patterns of infiltration, and to evaluate whether mild cases of umbilical phlebitis were associated with these lesions and were at risk of being missed. Vitelline vessel remnants were present in 4.2% of placentas examined. There were 5 vitelline vessel remnant histologic patterns identified providing insight into the vitelline vessel circulation. Funisitis, primarily neutrophilic, arising from vitelline vessel remnants was present in 70.3% of the 37 cords with vitelline vessel remnants. The presence of vitelline vessel remnant funisitis documents continued active circulation in these vascular structures, and vitelline vessel remnant funisitis was associated with the presence of other placental histological evidence of amniotic fluid infection in 53.8% of cases. The author also reviews normal embryology and the pathology of vitelline vessel remnants.

Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant's cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls' caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.0). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of comprehensive cord care practices in the antenatal care educational package.

Umbilical Cord Care in the Newborn Infant

Postpartum infections remain a leading cause of neonatal morbidity and mortality worldwide. A high percentage of these infections may stem from bacterial colonization of the umbilicus, because cord care practices vary in reflection of cultural traditions within communities and disparities in health care practices globally. After birth, the devitalized umbilical cord often proves to be an ideal substrate for bacterial growth and also provides direct access to the bloodstream of the neonate. Bacterial colonization of the cord not infrequently leads to omphalitis and associated thrombophlebitis, cellulitis, or necrotizing fasciitis. Various topical substances continue to be used for cord care around the world to mitigate the risk of serious infection. More recently, particularly in high-resource countries, the treatment paradigm has shifted toward dry umbilical cord care. This clinical report reviews the evidence underlying recommendations for care of the umbilical cord in different clinical settings.

Effect of 4 % chlorhexidine on cord colonization among hospital and community births in India: a randomized controlled study

BACKGROUND

Infections are the single most important cause of neonatal mortality in developing countries. Results from trials in Asia evaluating the effect of chlorhexidine on neonatal mortality have been encouraging but limited data are available on the impact of cord cleansing on bacterial colonization. Further, no data from facility deliveries and impact with time is available. This pilot study was aimed to evaluate the impact of 4 % commercially prepared chlorhexidine on cord colonization and density of colonization among newborns in India.

METHODS

Three hundred twenty-six newborns (hospital-247; community-79) were enrolled within 24 h of birth and randomly assigned to one of three groups: chlorhexidine, placebo or dry cord care. Umbilical swabs were collected at baseline, 2- and 48- hours after intervention application.

RESULTS

At baseline, growth positivity (any bacterial growth) was 20 % (50 of 247 swabs) and 81 % (64 of 79 swabs) among hospital and community born neonates, respectively. In both settings, chlorhexidine compared to placebo and dry cord care, reduced colonization following 2- and 48-hour post application. Chlorhexidine significantly reduced 48-hour post application colony counts in comparison to placebo [Hospital: mean difference = -1.01; 95 % CI: -1.72, -0.30 Community: mean difference = -1.76; 95 % CI: -2.60, -0.93] and dry cord care [Hospital: mean difference = -1.16; 95 % CI: -1.93, -0.39 Community: mean difference = -2.23; 95 % CI: -3.18, -1.29]. Differences were similar for gram-positive and gram-negative bacteria.

CONCLUSIONS

Cord cleansing with 4 % chlorhexidine soon after birth reduced colonization as well as density of colonization significantly; however this pilot study does not address the impact of chlorhexidine on mortality. The control preparation neither increased or decreased colonization.

TRIAL REGISTRATION

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov: NCT01528852, Registered February 7, 2012.

Infection of Internal Umbilical Remnant in Foals by Clostridium sordellii

Omphalitis and the resulting septicemia contribute to perinatal mortality in several animal species. In foals, the most important causes of omphalitis are Escherichia coli and Streptococcus zooepidemicus. However to date, no information has been published about the role of Clostridium sordellii in these infections. In this paper, we describe 8 cases of perinatal mortality in foals associated with internal umbilical remnant infection by C. sordellii. The foals studied were between 12 and 21 days old at the time of death, and various breeds were represented in the group. Five of the foals were male and 3 were female. The diagnosis was established on the basis of the detection of C. sordellii by 3 methods (culture, fluorescent antibody test, and immunohistochemistry) and on gross and histopathologic findings. All foals had acute peritonitis, and the internal umbilical remnant was thickened by edema, hemorrhage, and fibrosis. A moderate amount of serosanguinous fluid with fibrin strands was present in the pericardial sac and pleural cavity. Histopathologically, the urachus and umbilical arterial walls were thickened by edema and exhibited hemorrhage, fibrin, and leukocytic infiltration. Gram-positive bacterial rods were observed in subepithelial areas of the urachus, the adventicia of umbilical arteries, and interstitium of the internal umbilical remnant. On the basis of these findings, we suggest that C. sordellii should be considered in the differential diagnosis for infections of the internal umbilical remnant in foals.

Funisitis Associated with Leptospiral Abortion in an Equine Placenta

Funisitis, inflammation of the umbilical cord, is well recognized in human placentas. This report describes a case of funisitis associated with leptospiral infection in the placenta of a Thoroughbred foal born prematurely. The umbilical cord had diffuse superficial yellow discoloration along its entire length. Microscopic evaluation showed an exudate of neutrophils admixed with fibrin on the surface. Warthin-Starry staining showed spirochetes in the Wharton's jelly of the umbilical cord. A locally extensive, severe placentitis not involving the star and allantoic cystic hyperplasia were the other lesions observed in the allantochorion. Leptospira funisitis is similar to the funisitis of congenital syphilis in humans, although there are some major microscopic differences. in Leptospira funisitis, lesions were limited to the cord surface, whereas in lesions in human umbilical cords with Treponema pallidum infection, the changes are observed mostly around the vessels and in the Wharton's jelly.

Chlorhexidine skin or cord care for prevention of mortality and infections in neonates

BACKGROUND

Affordable, feasible and efficacious interventions to reduce neonatal infections and improve neonatal survival are needed. Chlorhexidine, a broad spectrum topical antiseptic agent, is active against aerobic and anaerobic organisms and reduces neonatal bacterial colonisation and may reduce infection.

OBJECTIVES

To evaluate the efficacy of neonatal skin or cord care with chlorhexidine versus routine care or no treatment for prevention of infections in late preterm or term newborn infants in hospital and community settings.

SEARCH METHODS

We searched CENTRAL, latest issue of The Cochrane Library, MEDLINE (1966 to November 2013), EMBASE (1980 to November 2013), and CINAHL (1982 to November 2013). Ongoing trials were detected by searching the following databases: www.clinicaltrials.gov and www.controlled-trials.com.

SELECTION CRITERIA

Cluster and individual patient randomised controlled trials of chlorhexidine use (for skin care, or cord care, or both) in term or late preterm neonates in hospital and community settings were eligible for inclusion. Three authors independently screened and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, and assessed study risk of bias. The quality of evidence for each outcome was assessed using GRADE. We calculated pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals (CIs), and presented results using GRADE 'Summary of findings' tables.

MAIN RESULTS

We included 12 trials in this review. There were seven hospital-based and five community-based studies. In four studies maternal vaginal wash with chlorhexidine was done in addition to neonatal skin and cord care. Newborn skin or cord cleansing with chlorhexidine compared to usual care in hospitalsLow-quality evidence from one trial showed that chlorhexidine cord cleansing compared to dry cord care may lead to no difference in neonatal mortality (RR 0.11, 95% CI 0.01 to 2.04). Moderate-quality evidence from two trials showed that chlorhexidine cord cleansing compared to dry cord care probably reduces the risk of omphalitis/infections (RR 0.48, 95% CI 0.28 to 0.84).Low-quality evidence from two trials showed that chlorhexidine skin cleansing compared to dry cord care may lead to no difference in omphalitis/infections (RR 0.88, 95% CI 0.56 to 1.39). None of the studies in this comparison reported effects of the treatments on neonatal mortality. Newborn skin or cord cleansing with chlorhexidine compared to usual care in the communityHigh-quality evidence from three trials showed that chlorhexidine cord cleansing compared to dry cord care reduces neonatal mortality (RR 0.81, 95% CI 0.71 to 0.92) and omphalitis/infections (RR 0.48, 95% CI 0.40 to 0.57).High-quality evidence from one trial showed no difference between chlorhexidine skin cleansing and usual skin care on neonatal mortality (RR 1.03, 95% CI 0.87 to 1.23). None of the studies in this comparison reported effects of the treatments on omphalitis/infections. Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in hospitalsModerate-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.98, 95% CI 0.67 to 1.42). High-quality evidence from two trials showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on the risk of infections (RR 0.93, 95% CI 0.82 to 1.16).Findings from one trial showed that maternal vaginal cleansing in addition to total body cleansing results in increased risk of hypothermia (RR 1.33, 95% CI 1.19 to 1.49). Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in the communityLow-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.20, 95% CI 0.01 to 4.03). Moderate-quality evidence from one trial showed that maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention probably reduces the risk of neonatal infections (RR 0.69, 95% CI 0.49 to 0.95). These studies did not report effect on omphalitis.

AUTHORS' CONCLUSIONS

There is some uncertainty as to the effect of chlorhexidine applied to the umbilical cords of newborns in hospital settings on neonatal mortality. The quality of evidence for the effects on infection are moderate for cord application and low for application to skin. There is high-quality evidence that chlorhexidine skin or cord care in the community setting results in a 50% reduction in the incidence of omphalitis and a 12% reduction in neonatal mortality. Maternal vaginal chlorhexidine compared to usual care probably leads to no difference in neonatal mortality in hospital settings. Maternal vaginal chlorhexidine compared to usual care results in no difference in the risk of infections in hospital settings. The uncertainty over the effect of maternal vaginal chlorhexidine on mortality outcomes reflects small sample sizes and low event rates in the community settings.

Umbilical cord antiseptics for preventing sepsis and death among newborns

The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and synthesise existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national license to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online free of charge through www.thecochranelibrary.com

Umbilical cord antiseptics for preventing sepsis and death among newborns

BACKGROUND

The umbilical cord is a structure made of blood vessels and connective tissue that connects the baby and placenta in utero. The umbilical cord is cut after birth, which separates the mother and her baby both physically and symbolically. Omphalitis is defined as infection of the umbilical cord stump. Tracking of bacteria along the umbilical vessels may lead to septicaemia that can result in neonatal morbidity and mortality, especially in developing countries.

OBJECTIVES

To determine the effect of application of antimicrobials on newborn's umbilical cord versus routine care for prevention of morbidity and mortality in hospital and community settings.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2012). In addition, we also searched LILACS (1982 to 11 October 2012) and HERDIN NeON (October 2012)

SELECTION CRITERIA

We included randomized, cluster-randomized and quasi-randomized controlled trials of topical cord care compared with no topical care, and comparisons between different forms of care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, trial quality and subsequently extracted data. Data were checked for accuracy.

MAIN RESULTS

The search identified 77 trials. We included 34 trials in the review involving 69,338 babies, five studies are awaiting classification and there are two ongoing community trials. Included studies were conducted in both developed and developing countries. Among the 34 included trials, three were large, cluster-randomized trials conducted in community settings in developing countries and 31 studies were conducted in hospital settings mostly in developed countries. Data for community and hospital studies were analyzed separately. The three trials conducted in community settings contributed 78% of the total number of children included in this review. Of the trials conducted in hospital settings, the majority had small sample sizes. There were 22 different interventions studied across the included trials and the most commonly studied antiseptics were 70% alcohol, triple dye and chlorhexidine.Only one antiseptic, chlorhexidine was studied in community settings for umbilical cord care. Three community trials reported data on all-cause mortality that comprised 1325 deaths in 54,624 participants and combined results showed a reduction of 23% (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.63 to 0.94, random-effects, T² = 0.02, I² = 50%) in the chlorhexidine group compared with control. The reduction in omphalitis ranged from 27% to 56% depending on the severity of infection. Cord separation time was increased by 1.7 days in the chlorhexidine group compared with dry cord care (mean difference (MD) 1.75 days, 95% CI 0.44 to 3.05, random-effects, T² = 0.88, I² = 100%). Washing of umbilical cord with soap and water was not advantageous compared with dry cord care in community settings.Among studies conducted in hospital settings, no study reported data for mortality or tetanus. No antiseptic was advantageous to reduce the incidence of omphalitis compared with dry cord care in hospital settings. Topical triple dye application reduced bacterial colonization with Staphylococcus aureus compared with dry cord care (average RR 0.15, 95% CI 0.10 to 0.22, four studies, n = 1319, random-effects, T² = 0.04, I² = 24%) or alcohol application (average RR 0.45, 95% CI 0.25 to 0.80, two studies, n = 487, random-effects, T² = 0.00, I² = 0%). There was no advantage of application of alcohol and triple dye for reduction of colonization with streptococcus. Topical alcohol application was advantageous in reduction of colonization with Enterococcus coli compared with dry cord care (average RR 0.73, 95% CI 0.58 to 0.92, two studies, n = 432, random-effects, T² = 0.00, I² = 0%) and in a separate analysis, triple dye increased the risk of colonization compared with alcohol (RR 3.44, 95% CI 2.10 to 5.64, one study, n = 373). Cord separation time was significantly increased with topical application of alcohol (MD 1.76 days, 95% CI 0.03 to 3.48, nine studies, n = 2921, random-effects, T² = 6.54, I² = 97%) and triple dye (MD 4.10 days, 95% CI 3.07 to 5.13, one study, n = 372) compared with dry cord care in hospital settings. The number of studies was insufficient to make any inference about the efficacy of other antiseptics.

AUTHORS' CONCLUSIONS

There is significant evidence to suggest that topical application of chlorhexidine to umbilical cord reduces neonatal mortality and omphalitis in community and primary care settings in developing countries. It may increase cord separation time however, there is no evidence that it increases risk of subsequent morbidity or infection.There is insufficient evidence to support the application of an antiseptic to umbilical cord in hospital settings compared with dry cord care in developed countries.

The effect of cord cleansing with chlorhexidine on neonatal mortality in rural Bangladesh: a community-based, cluster-randomised trial

BACKGROUND

Up to half of neonatal deaths in high mortality settings are due to infections, many of which can originate through the freshly cut umbilical cord stump. We aimed to assess the effectiveness of two cord-cleansing regimens with the promotion of dry cord care in the prevention of neonatal mortality.

DESIGN

We did a community-based, parallel cluster-randomised trial in Sylhet, Bangladesh. We divided the study area into 133 clusters, which were randomly assigned to one of the two chlorhexidine cleansing regimens (single cleansing as soon as possible after birth; daily cleansing for 7 days after birth) or promotion of dry cord care. Randomisation was done by use of a computer-generated sequence, stratified by cluster-specific participation in a previous trial. All livebirths were eligible; those visited within 7 days by a local female village health worker trained to deliver the cord care intervention were enrolled. We did not mask study workers and participants to the study interventions. Our primary outcome was neonatal mortality (within 28 days of birth) per 1000 livebirths, which we analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT00434408.

RESULTS

Between June, 2007, and September, 2009, we enrolled 29 760 newborn babies (10 329, 9423, and 10 008 in the multiple-cleansing, single-cleansing, and dry cord care groups, respectively). Neonatal mortality was lower in the single-cleansing group (22·5 per 1000 livebirths) than it was in the dry cord care group (28·3 per 1000 livebirths; relative risk [RR] 0·80 [95% CI] 0·65-0·98). Neonatal mortality in the multiple-cleansing group (26·6 per 1000 livebirths) was not statistically significantly lower than it was in the dry cord care group (RR 0·94 [0·78-1·14]). Compared with the dry cord care group, we recorded a statistically significant reduction in the occurrence of severe cord infection (redness with pus) in the multiple-cleansing group (risk per 1000 livebirths=4·2 vs risk per 1000 livebirths=1·2; RR 0·35 [0·15-0·81]) but not in the single-cleansing group (risk per 1000 livebirths=3·3; RR 0·77 [0·40-1·48]).

INTERPRETATION

Chlorhexidine cleansing of a neonate's umbilical cord can save lives, but further studies are needed to establish the best frequency with which to deliver the intervention.

FUNDING

United States Agency for International Development and Save the Children's Saving Newborn Lives program, through a grant from the Bill & Melinda Gates Foundation.

Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial

BACKGROUND

Umbilical cord infection (omphalitis) is a risk factor for neonatal sepsis and mortality in low-resource settings where home deliveries are common. We aimed to assess the effect of umbilical-cord cleansing with 4% chlorhexidine (CHX) solution, with or without handwashing with antiseptic soap, on the incidence of omphalitis and neonatal mortality.

METHODS

We did a two-by-two factorial, cluster-randomised trial in Dadu, a rural area of Sindh province, Pakistan. Clusters were defined as the population covered by a functional traditional birth attendant (TBA), and were randomly allocated to one of four groups (groups A to D) with a computer-generated random number sequence. Implementation and data collection teams were masked to allocation. Liveborn infants delivered by participating TBAs who received birth kits were eligible for enrolment in the study. One intervention comprised birth kits containing 4% CHX solution for application to the cord at birth by TBAs and once daily by family members for up to 14 days along with soap and educational messages promoting handwashing. One intervention was CHX solution only and another was handwashing only. Standard dry cord care was promoted in the control group. The primary outcomes were incidence of neonatal omphalitis and neonatal mortality. The trial is registered with ClinicalTrials.gov, number NCT00682006.

FINDINGS

187 clusters were randomly allocated to one of the four study groups. Of 9741 newborn babies delivered by participating TBAs, factorial analysis indicated a reduction in risk of omphalitis with CHX application (risk ratio [RR]=0·58, 95% CI 0·41-0·82; p=0·002) but no evidence of an effect of handwashing (RR=0·83, 0·61-1·13; p=0·24). We recorded strong evidence of a reduction in neonatal mortality in neonates who received CHX cleansing (RR=0·62, 95 % CI 0·45-0·85; p=0·003) but no evidence of an effect of handwashing promotion on neonatal mortality (RR=1·08, 0·79-1·48; p=0·62). We recorded no serious adverse events.

INTERPRETATION

Application of 4% CHX to the umbilical cord was effective in reducing the risk of omphalitis and neonatal mortality in rural Pakistan. Provision of CHX in birth kits might be a useful strategy for the prevention of neonatal mortality in high-mortality settings.

FUNDING

The United States Agency for International Development.

Evaluation of group B Streptococci colonization rate in pregnant women and their newborn

Group B Streptococcus (GBS) is one of the most important bacteria in the majority of maternal and neonatal infections, such as chorioamnionitis, endometritis, bacteremia, sepsis and meningitis. During pregnancy, GBS screening is one of the recommended strategies that are recommended by center of disease control (CDC). This study was aimed to determine the rectovaginal colonization prevalence among pregnant women, and also the rate of transmission to their offspring. Between June 2008 and April 2009, two hundred pregnant women admitted in department of Obstetrics and Gynecology (Ghaem Hospital, Mashhad, Iran) were enrolled in present study. Samples from maternal rectum and vagina as well as neonate ear and umbilical cord were taken for culture. The colonization rate for GBS in pregnant women and their neonates was around 6% and 5% respectively. All the carrier mothers were cases with premature rupture of membranes (at least 18 hours before delivery). In terms of colonization, there was a significant correlation between mothers and newborns, and more than 80% of neonates from GBS carrier mothers were colonized by GBS.

[Alferecía and the first cases of tetanus neonaturum described in Chile in 1894]

Federico Puga Borne presented the first two cases of known Chilean tetanus neonatorum in 1891. These cases had a fatal course, were poorly described and had no necropsy. The presentation was done in a regular session of the Sociéte Scientifique du Chili, founded in 1891 by a French citizen settled in the country, and published in the Actes de la Sociéte Scientifique du Chili. At this time, tetanus had never been seen in a newborn in Chile, while it was very common in other South American countries; its popular name was alferecía, but this term covered many other neurological disorders.

Community-based health workers achieve high coverage in neonatal intervention trials: a case study from Sylhet, Bangladesh

A large proportion of four million neonatal deaths occur each year during the first 24 hours of life. Research is particularly needed to determine the efficacy of interventions during the first 24 hours. Large cadres of community-based workers are required in newborn-care research both to deliver these interventions in a standardized manner in the home and to measure the outcomes of the study. In a large-scale community-based efficacy trial of chlorhexidine for cleansing the cord in north-eastern rural Bangladesh, a two-tiered system of community-based workers was established to deliver a package of essential maternal and newborn-care interventions and one of three umbilical cord-care regimens. At any given time, the trial employed approximately 133 community health workers--each responsible for 4-5 village health workers and a population of approximately 4,000. Over the entire trial period, 29,760 neonates were enrolled, and 87% of them received the intervention (their assigned cord-care regimen) within 24 hours of birth. Approaches to recruitment, training, and supervision in the study are described. Key lessons included the importance of supportive processes for community-based workers, including a strong training and field supervisory system, community acceptance of the study, consideration of the setting, study objectives, and human resources available.

[Influencing factors of umbilical cord separation in full-term newborns]

OBJECTIVE

To investigate the influencing factors for the time of umbilical cord separation in full-term newborns.

METHODS

The time of umbilical cord separation was recorded in 337 full-term newborns. Single factor and multifactor unconditioned logistic regression were performed to investigate the influencing factors of umbilical cord separation. Fourteen possible factors associated with the time of umbilical cord separation, including sex, gestational age, body weight, position of umbilical cord ligature, length of umbilical cord stump, umbilical cord diameter, cleanness of umbilical cord paster, hand cleanness of medical staff and family members and umbilical infection, were involved.

RESULTS

The single factor correlative analysis demonstrated that the position of umbilical cord ligature, length of umbilical cord stump, umbilical cord diameter, cleanness of umbilical cord paster, and umbilical infection were influencing factors for the time of umbilical cord separation (P<0.05). The multifactor unconditioned logistic regression analysis demonstrated four major influencing factors for umbilical cord separation: position of umbilical cord ligature, length of umbilical cord stump, cleanness of umbilical cord paster, and umbilical infection.

CONCLUSIONS

The following factors contribute to early separation of umbilical cord: the proper position of umbilical cord ligature (<0.5 cm to umbilical ring), the umbilical cord stump of <0.5 cm, keeping the umbilical cord paster clean and the prevention of umbilical infection.

Impact of clean delivery-kit use on newborn umbilical cord and maternal puerperal infections in Egypt

This cross-sectional cohort study explored the impact of the use of clean delivery-kit (CDK) on morbidity due to newborn umbilical cord and maternal puerperal infections. Kits were distributed from primary-care facilities, and birth attendants received training on kit-use. A nurse visited 334 women during the first week postpartum to administer a structured questionnaire and conduct a physical examination of the neonate and the mother. Results of bivariate analysis showed that neonates of mothers who used a CDK were less likely to develop cord infection (p = 0.025), and mothers who used a CDK were less likely to develop puerperal sepsis (p = 0.024). Results of multiple logistic regression analysis showed an independent association between decreased cord infection and kit-use [odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18-0.97, p = 0.041)]. Mothers who used a CDK also had considerably lower rates of puerperal infection (OR = 0.11, 95% CI 0.01-1.06), although the statistical strength of the association was of borderline significance (p = 0.057). The use of CDK was associated with reductions in umbilical cord and puerperal infections.

[Myth of neonatal umbilical cord care]

Umbilical cord care is a common practice after birth. Although most hospitals routinely use alcohol in the administration of cord care to newborns in Taiwan, the literature suggests that other different cord-care regimens may also be as or more effective. The purpose of this paper is to compare the effect of different cord-care regimens on cord separation time, colonization, omphalitis occurrence, and maternal satisfaction. Findings are hoped to provide nurses information essential to consider and select an optimal approach to umbilical cord care.

A neonatal specialist with recurrent methicillin-resistant Staphylococcus aureus (MRSA) carriage implicated in the transmission of MRSA to newborns

This study reports an investigation of outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) infection and colonization involving 17 newborns in the neonatal unit of a teaching hospital. A neonatal specialist colonized with MRSA that eventually became mupirocin-resistant was implicated as a recurrent source of transmission of MRSA to newborns.

Risk factors for umbilical cord infection among newborns of southern Nepal

Although umbilical cord infection contributes to neonatal mortality and morbidity and risk can be reduced with topical chlorhexidine, behavioral or other factors associated with cord infection in low-resource settings have not been examined. Data on potential risk factors for omphalitis were collected during a community-based, umbilical cord care trial in Nepal during 2002-2005. Newborns were evaluated in the home for signs of umbilical cord infection (pus, redness, and swelling). Omphalitis was defined as either pus discharge with erythema of the abdominal skin or severe redness (>2 cm extension from the cord stump) with or without pus. Multivariable regression modeling was used to examine associations between omphalitis and maternal, newborn, and household variables. Omphalitis was identified in 954 of 17,198 newborns (5.5%). Infection risk was 29% and 62% higher in infants receiving topical cord applications of mustard oil and other potentially unclean substances, respectively. Skin-to-skin contact (relative risk (RR) = 0.64, 95% confidence interval (CI): 0.43, 0.95) and hand washing by birth attendants (RR = 0.73, 95% CI: 0.64, 0.84) and caretakers (RR = 0.76, 95% CI: 0.60, 0.95) were associated with fewer infections. In this community, unhygienic newborn-care practices lead to continued high risk for omphalitis. In addition to topical antiseptics, simple, low-cost interventions such as hand washing, skin-to-skin contact, and avoiding unclean cord applications should be promoted by community-based health workers.

Ureaplasma urealyticum and Mycoplasma hominis presence in umbilical cord is associated with pathogenesis of funisitis

Ureaplasma urealyticum (U. urealyticum) and Mycoplasma hominis (M. hominis) are known to cause an intrauterine infection for preterm deliveries, but it is not known whether they are actually pathogenically involved in the development of funisitis, chorioamnionitis (CAM), and chronic lung disease (CLD) in preterm infants. Our purpose was to identify U. urealyticum and M. hominis in the umbilical cord, placenta, and tracheal aspirate (TA) or gastric fluid (GF) of preterm infants, and to clarify whether they contribute to funisitis, CAM, and CLD. Of 128 preterm infants, 86 umbilical cords, 83 placentas, and 84 TA or GF samples obtained postnatally from preterm infants were examined. U. urealyticum and M. hominis were detected by polymerase chain reaction and prospectively analyzed to determine whether the presence of U. urealyticum or M. hominis can lead to the development of funisitis, CAM, and CLD. U. urealyticum or M. hominis was isolated in nine (10.5%) of the umbilical cords, five (6.0%) of the placentas, and fifteen (17.9%) of the TA or GF samples. Funisitis was identified in all umbilical cords with U. urealyticum or M. hominis, but in only 13% of the umbilical cords without U. urealyticum and M. hominis (p < 0.001). Placentas and TA or GF with or without U. urealyticum and M. hominis did not show significant differences with regard to the development of CAM or CLD. Our results suggest that U. urealyticum and M. hominis presence is associated with the pathogenesis of funisitis, but not of CAM or CLD.

The Alabama Preterm Birth Study: intrauterine infection and placental histologic findings in preterm births of males and females less than 32 weeks

OBJECTIVE

The objective of the study was to determine whether there are differences in the placental histology and various markers of infection/inflammation between preterm male and female fetuses.

STUDY DESIGN

The placentas and umbilical cords of 446 infants born at 23 to 32 weeks were examined histologically, cultured for aerobic and anaerobic bacteria and mycoplasmas, and the interleukin-6 levels in cord blood determined.

RESULTS

Male infants were significantly more likely to have positive placental cultures than female infants (63.4% versus 51.8%, P = .01, odds ratio 1.5, 1.0 to 2.4). Cord blood Mycoplasma hominis and Ureaplasma urealyticum infections were marginally more common in male than female fetuses (27.6% versus 19.2%, P = .06, odds ratio 1.7, 0.9 to 2.9), but cord blood interleukin-6 levels were not different between male and female fetuses. The only significant histologic difference between male and female placentas was in decidual lymphoplasmacytic cell infiltration (6.3% versus 0.9%, P = .003, odds ratio 8.3, 1.8 to 39.0). Males had a higher percentage of decidual lymphohistiocytic cell infiltration, but the differences were not significant (11.3% versus 7.4%, P = .160, odds ratio 1.6, 0.8 to 3.2).

CONCLUSION

Male infants were significantly more likely to have positive placental membrane cultures than female infants. Decidual lymphoplasmacytic cell infiltrations were more common in male versus female placentas, confirming a previous observation and suggesting that a maternal immune reaction to fetal tissue may be more common in male fetuses.

Optimal surveillance culture sites for detection of methicillin-resistant Staphylococcus aureus in newborns

We describe two outbreaks among newborns, one caused by community-associated methicillin-resistant Staphylococcus aureus (MRSA) and the other by hospital-associated MRSA. The umbilicus, rectum, and nares were tested for colonization. We found that no single body site had optimal sensitivity when tested alone. The combination of umbilical and nasal swabs achieved a sensitivity of >90%.

Development of clinical sign based algorithms for community based assessment of omphalitis

BACKGROUND

In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions.

OBJECTIVE

To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis.

DESIGN

Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated.

RESULTS

Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific.

CONCLUSIONS

Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

Isolation of Commensal Bacteria from Umbilical Cord Blood of Healthy Neonates Born by Cesarean Section

In a previous study, lactic acid bacteria were isolated from meconium obtained from healthy neonates born by cesarean section. Such a finding suggested that term fetuses are not completely sterile, and that a mother-to-child efflux of commensal bacteria may exist. Therefore, presence of such bacteria in umbilical cord blood of healthy neonates born by elective cesarean section was investigated. The blood samples were submitted to an enrichment step and then inoculated onto agar plates. All the identified isolates belonged to the genus Enterococcus, Streptococcus, Staphylococcus, or Propionibacterium. Later, a group of pregnant mice were orally inoculated with a genetically labeled E. faecium strain previously isolated from breast milk of a healthy woman. The labeled strain could be isolated and polymerase chain reaction detected from the amniotic fluid of the inoculated animals. In contrast, it could not be detected in the samples obtained from a noninoculated control group.

Congenital Candida glabrata infection without specific nodules on the placenta and umbilical cord

Two extremely premature infants died as a result of congenital Candida glabrata infection, and their placentas and umbilical cords were free of macroscopic Candida nodules. Because non-Candida albicans Candida infections are less likely to produce necrotic foci, we should not exclude Candida infections in the absence of macroscopic nodules on the placenta and umbilical cord.

A randomized study of 3 umbilical cord care regimens at home in thai neonates: comparison of time to umbilical cord separation, parental satisfaction and bacterial colonization

OBJECTIVE

To compare time to cord separation, parental satisfaction and bacterial colonization, among 3 regimens of cord care at home.

STUDY DESIGN

Randomized controlled trial.

MATERIAL AND METHOD

Term infants were randomly assigned based on cord care regimens at home: 1) triple dye, 2) alcohol, and 3) no antiseptic agent. Timing of cord separation, and parental satisfaction were evaluated during the first month of age.

RESULTS

185 infants were recruited. Time to cord separation in infants of group I was significantly longer than in group 2 (p = 0.036) and group 3 (p = 0.003). The satisfaction scores of group I were significantly lower than those of group 2 and group 3. 180 culture specimens were performed and positive in all but none had omphalitis.

CONCLUSION

Triple dye delayed time to cord separation and was less satisfactory. The authors conclude that using alcohol or dry clean could be alternative ways of umbilical cord care at home.

Serotype distribution and mother-to-baby transmission rate of Streptococcus agalactiae among expectant mothers in Kuwait

INTRODUCTION

Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is a formidable pathogen that is commonly responsible for early-onset and late-onset infections with high morbidity and mortality in the neonatal period. Since this organism is usually acquired via the mother's birth canal during labor, this study investigated the maternal carriage rate, mother-to-baby transmission rate, and the common GBS serotypes found among expectant mothers and their babies in Kuwait.

METHODS

The setting was the Maternity Hospital, Kuwait. Low vaginal-anorectal swabs (LVRS) and urine specimens were collected from 847 pregnant women during labor. Ear and umbilical swabs from their new-born babies were also collected. Each specimen was cultured on selective Todd-Hewitt media. Isolates were identified and serotyped by established methods.

RESULTS

Of the 847 mothers, 124 (14.6%) were colonized and 74 (8.7%) babies were colonized, mainly at the umbilicus. The 124 GBS-positive mothers gave birth to 44 babies that were colonized by GBS at one or both sites, which corresponds to a mother-to-baby transmission rate of (35.5%). A total of 193 isolates were serotyped. The majority of the GBS isolates belonged to serotypes III (47; 24.3%), V (42; 21.8%), Ia (25; 12.9%), II and VI (15; 7.8%) each, and VII (11; 5.7%). Only 4 (2.1%) and 1 (0.5%) isolates belonged to serotypes Ib and IV respectively. No isolate belonged to serotype VIII and 33 (17.1%) were non-typable (NT).

Alcohol or traditional methods versus natural drying for newborn's cord care

This is a quasi-experimental study that aimed to compare the use of alcohol and traditional methods for newborn's cord care with a no-treatment approach, natural drying. The study also aimed to identify the factors associated with the occurrence of cord infection and time of cord separation. A convenient sample of 70 women with vaginal delivery, full-term and healthy babies was selected from postpartum departments of two university hospitals in Alexandria and Minia. A specially designed interview schedule was developed and utilized to collect data. Swabs were taken from the newborns' umbilical stumps on zero and 3rd day of birth to detect bacterial colonization. Follow-up was carried-out at home to assess methods used for cord care, babies' hygiene, cord infection and time of cord separation. The study revealed that traditional methods of cord care were used by women with higher mean age (30.8 +/- 7.8 years), from Minia (100%) or rural areas (71.4%), while alcohol and natural drying were used by women with lower mean age (27.7 +/- 4.8 and 24.8 +/- 6.5 years) respectively, from Alexandria (76% and 100%) respectively or urban areas (56% and 64.7%) respectively. Alcohol was used for male babies (76%), while traditional methods and natural drying were used for female babies (71.4% & 64.7%) respectively. Incidence of cord infection was significantly lower among natural drying group (35.3%), and no signs of systemic infection were observed among them. Rate of increase of bacterial colonization (from 0-3rd day of birth) was significantly higher in alcohol group (44%). It was relatively similar with presence or absence of cord infection (33.3 & 32.1) respectively. Mean time of cord separation was longer among alcohol group (6.4 +/- 2.4 days), as compared with natural drying group (4.7 +/- 1.9 days) and traditional methods group (3.4 +/- 0.7 days). Bathing baby while cord was attached was carried-out by all women of alcohol and natural drying groups, compared to only 28.6% of traditional methods group. Breast-feeding was significantly related to less incidence of cord infection (P= 0.008) and shorter time of cord separation (P= 0.002). Incidence of cord infection was significantly related to using cloth diaper (P= 0.015), using dry method for skin care (X(2) 2= 7.2917), giving tub bath (X(1)2 = 4.1788) and delaying the bath to the 7th day of birth (P= 0.050). Time of cord separation was significantly shorter with closed cord dressing (X(2)2= 20.4028), in Minia, during spring, among male babies (X(2)2= 15.0352), and in rural areas (X(2)2 = 9.7608). It was significantly longer with bathing the baby while cord was attached (X(2)2 = 27.9354), giving 2-3 baths/week or delaying the bath to the 7th day of birth (P= 0.049) and with using cloth diaper (P= 0.0467). So, moving from an intervention to a non- intervention, particularly in a healthy population should be applied to the healthy naturalistic approach to care advocated in nursing. Also, only through continuing efforts done to examine our assumptions about historic health care routines, will we be able to demonstrate evidence-based practice and to advance nursing care.

Double-blind comparative study on the care of the neonatal umbilical cord using 80% ethanol with or without chlorhexidine

We conducted a double-blind comparative study on the effectiveness of 80% ethanol (EtOH), with or without chlorhexidine (CHD), in the prevention of neonatal umbilical colonization by Staphylococcus aureus, the most frequently isolated pathogen on the neonatal umbilicus in the early period. A total of 100 neonates born at the National Tokyo Medical Centre from March to May 2000 and nursed at a maternity ward were enrolled. Forty-eight were randomly allocated to the group for whom umbilical cord disinfection was performed using 80% EtOH containing 0.5% CHD (CHD group) and 52 to disinfection with 80% EtOH alone (EtOH group). The mothers of the neonates and the nursing staff were unaware as to which disinfectant was being used. Disinfection of the umbilicus and the surrounding area was done immediately after birth and twice daily thereafter, after bathing and in the evening, throughout the hospitalization period. Specimens for bacterial culture were taken from the umbilical cord and surrounding skin on day 4 or 5 after birth. As a disinfectant susceptibility test, we checked the minimum killing concentration (MKC) of CHD and EtOH. There was no statistically significant difference between the two groups with respect to sex, gestation period, birthweight, APGAR score or delivery method. In the CHD group, S. aureus was isolated from 25% of the patients, while it was isolated from 57.7% in the EtOH group (P<0.001). In the CHD group, 50% of the S. aureus strains were MRSA, compared with 73.3% in the EtOH group (non-significant). All the S. aureus strains were killed by the combination of both CHD and EtOH at the concentrations used. In terms of the MKC90, there was no significant difference between the CHD group and the EtOH group. For the daily care of the neonatal umbilicus, disinfection using 80% EtOH containing CHD was found to be more effective than that using 80% EtOH alone in preventing colonization by S. aureus.

Changes in newborn bathing practices may increase the risk for omphalitis

Aseptic cord care, in conjunction with antibacterial skin care, has reduced the incidence of omphalitis specifically caused by Staphylococcus aureus. However, this practice has resulted in the emergence of resistant organisms that may pose a greater risk for newborn infections. Subsequently, many institutions have changed to dry cord care and nonantiseptic whole-body baths, a practice that has not been adequately studied to determine potential infectious risks. Three cases of omphalitis occurring after an institutional change to nonantiseptic whole-body baths are presented. Clinical diagnosis and treatment of omphalitis are reviewed. Recommendations for surveillance of omphalitis are offered.

"White dots on the placenta and red dots on the baby": congential cutaneous candidiasis--a rare disease of the neonate

Cutaneous congenital candidiasis (CCC) is a very rare disease of the term or premature infant consisting of a generalized rash at or shortly after birth usually without other signs or symptoms. The presence of white microabscesses on the placenta and umbilical cord of an infant with such a rash must suggest the diagnosis of CCC, which is always secondary to Candida chorioamnionitis but may pass unrecognized. Despite the high prevalence of vulvo-vaginitis in pregnant women, Candida chorioamnionitis is rare and CCC remains apparently extremely rare with just some hundred cases described. However, as the condition is essentially benign and self-limited, underdiagnosis is likely. As occasional systemic spread of Candida infection is described and maternal complications may arise, diagnosis and a close follow-up or treatment is of importance. We present two cases of CCC, stressing the importance of sharing clinical findings between obstetrician and neonatologist for the diagnosis and subsequent management.

Maternal and fetal inflammatory responses in unexplained fetal death

OBJECTIVE

The role of intra-amniotic infection in the etiology of fetal death has been proposed. This study was conducted to determine the prevalence of microbial invasion of the amniotic cavity (MIAC) and the frequency of maternal and/or fetal inflammation in patients presenting with a fetal death.

METHODS

A prospective study was conducted in patients with a fetal death. Amniocenteses were performed for clinical indications (karyotype), as well as to assess the microbiological and cytological state of the amniotic cavity. Fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas. An amniotic fluid white blood cell count and glucose determinations were also performed. Histological examination of the placenta was conducted to identify a maternal inflammatory response (acute chorioamnionitis) or a fetal inflammatory response (funisitis).

RESULTS

This study included 44 patients with intrauterine fetal death. The median gestational age at diagnosis was 30.1 weeks (range 16.3-40.4 weeks). One patient had documented MIAC (1/44). Acute histological chorioamnionitis was found in 20.9% (9/43), but a fetal inflammatory response was observed in only 2.3% (1/43) of cases. One patient had a positive amniotic fluid culture for Streptococcus agalactiae (group B streptococcus).

CONCLUSION

Histological chorioamnionitis was present in 20.9% of cases, but MIAC could be demonstrated with conventional microbiological techniques in only one case. A fetal inflammatory response was nine times less frequent than a maternal inflammatory response (maternal 20.9% vs. fetal 2.3%, p = 0.008) in cases of fetal death.

Effectiveness of topical chlorhexidine powder as an alternative to hexachlorophane for the control of Staphylococcus aureus in neonates

We routinely phage-type Staphylococcus aureus isolates from high-risk inpatients each week. This surveillance approach previously identified a five-year outbreak of a methicillin-susceptible S. aureus strain (MSSA, PT 53,85), which affected 202 babies on a regional neonatal unit. We previously reported this outbreak and the multiple staged infection control measures that were required to end it. These included strict emphasis on hand hygiene, environmental and staff surveillance sampling, application of topical triclosan solution and hexachlorophane powder, aseptic handling of a skin protectant material, and use of topical mupirocin for staff nasal carriers of the endemic MSSA strain and for babies colonized or infected with S. aureus. In summer 2000 topical hexachlorophane powder became unavailable and we therefore substituted topical 1% chlorhexidine powder as part of routine umbilical decontamination. We have continued prospective S. aureus surveillance for the past five years to monitor the effect of this practice change. We observed a continued decline in the numbers of monthly MSSA isolates from neonatal unit babies. Since the substitution of chlorhexidine for hexachlorophane, the median monthly number of MRSA isolates has been 0.5 (range 0-4). Only sporadic S. aureus PT 53,85 isolates were recovered. Control of S. aureus in our regional neonatal unit, in particular an endemic MSSA strain, was maintained when topical umbilical hexachlorophane powder was substituted with 1% chlorhexidine powder.

Novel Echogenic Drug-Immunoliposomes for Drug Delivery

RATIONALE AND OBJECTIVES

We have developed novel echogenic immunoliposomes (ELIPs) that can be antibody-conjugated for the specific highlighting of atheroma and atheroma components. The utility of these agents for regional drug delivery has not been evaluated previously. We chose to use an antibiotic as the prototype drug. The concept that an infectious agent may affect the development and progression of atherosclerosis has stimulated trials on the use of antibiotics for coronary syndromes. However, these agents are given systemically with concomitant problems. Development of an agent for local drug delivery may obviate adverse effects and improve treatment efficacy. The aim of this study was to evaluate the potential of our ELIPs for drug incorporation and to demonstrate efficient drug delivery to cultured cells.

METHODS

Azithromycin was incorporated into the ELIPs during development. Free drug was removed with a Sephadex G-50 column. Acoustic properties were evaluated using an intravascular ultrasound catheter and quantified by computer-assisted videodensitometry. Human umbilical arterial endothelial cells were infected with Chlamydia pneumoniae. Cells were treated with the drug-ELIP complexes, and infection-forming units were counted using fluorescence techniques.

RESULTS

We were able to incorporate a drug into the ELIPs with retention of acoustic properties. The drug-ELIP complex demonstrated effective inhibition of microbial growth in endothelial cells (P < 0.001 vs. empty liposomes and control).

CONCLUSIONS

We have developed a novel acoustic drug-liposomal agent that can deliver drugs to cultured cells. Although in vivo translation is required, this technique has potential for site-specific drug delivery.

Does umbilical cord care in preterm infants influence cord bacterial colonization or detachment?

OBJECTIVE

The purpose of the present study was to compare alcohol versus natural drying for umbilical cord care in preterm infants and to examine its effects on bacterial colonization and cord detachment.

STUDY DESIGN AND METHODS

Eligible infants <34 weeks gestation admitted to the NICU were randomized to receive either umbilical cleansing with 70% isopropyl alcohol at each diaper change or natural drying. Umbilical stump cultures were performed at 12 to 24 hours, 72 hours, 7 days, and 14 days of age.

RESULTS

A total of 109 infants were enrolled; 102 completed the study. Analyses revealed that the median cord detachment time was significantly shorter in the natural drying group compared to the alcohol group (13.0 versus 16.0 days; p=0.003). There were no cases of local umbilical infection in either group.

CONCLUSION

Based on the present study, it appears that natural drying is a safe and effective means of umbilical cord care in preterm infants.

Changing spectrum of neonatal omphalitis

STUDY OBJECTIVE

Risk factors and clinical and bacteriologic profile of neonates with omphalitis were studied during a 5-year period (January 1994 through December 1998).

DESIGN AND SETTING

Prospective observational study in a Special Care Baby Unit of a regional referral hospital in Oman.

PATIENTS

Consecutive cases of neonatal omphalitis admitted at a regional special care baby unit during a 5-year period formed the study cohort; 207 cases of omphalitis among 11 260 births (9528 hospital births and 1732 home births) were studied.

METHODS

Proportional risk factors and clinical, bacteriologic and relevant investigational profiles and outcomes were studied in neonates with omphalitis. For the study purpose omphalitis was classified into four categories based on severity.

RESULTS

The incidence of omphalitis was higher in home births (P < 0.001), in neonates with an intrapartum setup for sepsis (P < 0.05) and in low birth weight (weight <2500 grams) neonates (P < 0.05). Staphylococcus aureus was the most common pathogen isolated from umbilical swabs followed by Escherichia coli and Klebsiella spp. The incidence and severity of omphalitis showed a proportionate decline with reduction of home births during the 5-year study period.

CONCLUSION

The spectrum and severity of neonatal omphalitis are on the decline in conformity with the decline in home births and septic deliveries besides general improvement in maternal and child health care delivery in Oman.

Role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the evidence

In developing countries umbilical cord infections constitute a major cause of neonatal morbidity and pose significant risk for mortality, whereas outbreaks of cord infections continue to occur in developed country nurseries. Cord infections in developing countries can be prevented through increasing access to tetanus toxoid immunization during pregnancy, promoting clean cord care and reducing harmful cord applications and behaviors. Interventions introduced in both developed and developing countries to reduce exposure of the cord to infectious pathogens include clean cord cutting, hand-washing before and after handling the baby, bathing of the infant with antimicrobial agents and application of antimicrobials to the cord. Despite the importance of umbilical cord care, both traditionally and medically, there have been few randomized trials investigating the impact of different cord care regimens on rates of local or systemic infections, particularly in developing countries. This review examines available data on umbilical cord care, with a particular focus on those comparing rates of bacterial colonization and/or rates of cord infection among neonates receiving different umbilical cord care regimens. Although most investigators agree that topical antimicrobials reduce bacterial colonization of the cord, a firm relationship between colonization and infection has not been established. Further research in developed countries, including follow-up beyond hospital discharge, is required before advising on "best cord care practices." The paucity of published reports from developing countries indicates the need to investigate the impact of antimicrobial applications on cord and systemic infections in a community-based, prospective manner.

To dye or not to dye: a randomized, clinical trial of a triple dye/alcohol regime versus dry cord care

OBJECTIVE

The use of antibacterial agents to clean and dry the stump of the newborn's umbilical cord after birth has recently been abandoned by many neonatal units in favor of dry cord care. The objective of this study was to compare cord bacterial colonization and morbidity among newborns whose cords were treated with triple dye and alcohol versus dry cord care.

METHODOLOGY

We randomly allocated 766 newborns to either 2 applications of triple dye to the umbilical cord stump on the day of birth with alcohol swabbing twice daily until the cord fell off (n = 384) or dry care (n = 382). Dry care consisted of spot cleaning soiled skin in the periumbilical area with soap and water, wiping it with a dry cotton swab or cloth, and allowing the area to air dry. Umbilical stumps on all subjects were swabbed and cultured. Community health nurses visiting at 2 or 3 days after hospital discharge observed the stump for signs of infection. Follow-up phone calls were made to mothers within 3 weeks of discharge.

RESULTS

One infant in the dry care group was diagnosed with omphalitis. The umbilical stump was colonized with alpha-hemolytic streptococcus and coagulase-negative staphylococcus. Infants in the dry care group were significantly more likely to be colonized with Escherichia coli (34.2% vs 22.1%), coagulase-negative staphylococci (69.5% vs 50.5%), Staphylococcus aureus (31.3% vs 2.8%), and group B streptococci (11.7% vs 6.0%). Community health nurses were significantly more likely to observe exudate (7.4% vs 0.3%) and foul odor (2.9% vs 0.7%) among infants allocated to the dry care group during the home visit.

CONCLUSIONS

Omphalitis remains a clinical issue. Cessation of bacteriocidal care of the umbilical stump must be accompanied by vigilant attention to the signs and symptoms of omphalitis.

Cutaneous and subcutaneous infections in newborns due to anaerobic bacteria

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

[A Cochrane review on the umbilical cord care and prevention of infections. Antiseptic solutions are not necessary in developed countries but life-saving in developing countries]

One million newborn infants die every year by bacterial infections, which often have entered the body via the umbilicus. A Cochrane systematic review on "Topical umbilical cord care at birth" by J Zupan and P Garner is reviewed. Zupan and Garner conclude that simply to keep the umbilical cord dry and clean is sufficient for healthy, term neonates in rich countries; disinfectants do not offer any advantage. However, cleaning the umbilical cord with disinfectants may reduce the risk of serious bacterial infections in babies in poor countries or in neonatal wards. Observational studies in poor countries indicate that the life of numerous infants can be saved if pregnant women are vaccinated against tetanus and disinfectants are substituted for harmful cord care traditions. This Cochrane review is credible, but it should be updated and considered tentative since no data on sepsis are included. The search strategy should be better described and observational studies (case control and cohort studies) from poor countries should be included since there are no randomized control trials from these countries.