1: Crit Care Med. 2007 Dec;35(12):2677-85.Comment on:Crit Care Med. 2007 Dec;35(12):2852-4. Crit Care Med. 2007 Dec;35(12):2855-6.Use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septicshock
.Kreymann KG, de Heer G, Nierhaus A, Kluge S.Department of Intensive Care, University Medical Centre, Hamburg-Eppendorf,Germany. kreymann@uke.uni-hamburg.deOBJECTIVE: There is ongoing debate about the efficacy of polyvalentimmunoglobulins as adjunctive therapy for sepsis or septic shock. Twometa-analyses by the Cochrane collaboration calculated a significant reduction inmortality. However, data of the largest study were missing in one, and a subsetof four high-quality studies failed to show an effect in the other. To broadenthe database, we performed a meta-analysis of all randomized controlled studiespublished so far. DATA SOURCE: MEDLINE, EMBASE, Cochrane Library of randomizedtrials, and personal files. STUDY SELECTION: Meta-analysis of all publishedrandomized controlled studies published on polyvalent immunoglobulins (Ig) fortreatment of sepsis or septic shock in adults, children, or neonates. DATAEXTRACTION: Twenty-seven trials with a total of 2,202 patients fulfilled theinclusion criteria. DATA SYNTHESIS: As the immunologic state of neonates isdifferent than that of adults or older children, data were evaluated separatelyfor each group. Fifteen trials on 1,492 adults could be included. The pooledeffect on mortality was a relative risk of death (RR) of 0.79 (95% confidenceinterval [CI] 0.69-0.90, p
Sepsis in the newborn.
Sankar MJ, Agarwal R, Deorari AK, Paul VK.
Division of Neonatology, Department of Pediatrics, All India Institute of MedicalSciences, Ansari Nagar, New Delhi, India.
Infections are the single largest cause of neonatal deaths globally. According toNational Neonatal Perinatal Database (2002-03), the incidence of neonatal sepsis in India was 30 per 1000 live-births; klebsiella pneumoniae and staphylococcusaureus were the two most common organisms isolated. Based on the onset, neonatal sepsis is classified into two major categories: early onset sepsis, which usuallypresents with respiratory distress and pneumonia within 72 hours of age and late onset sepsis, that usually presents with septicemia and pneumonia after 72 hours of age. Clinical features of sepsis are non-specific in neonates and a high indexof suspicion is required for the timely diagnosis of sepsis. Although bloodculture is the gold standard for the diagnosis of sepsis, culture reports wouldbe available only after 48-72 hours. A practical septic screen for the diagnosis of sepsis has been described and some suggestions for antibiotic use have beenincluded in the protocol.1: JAMA. 2005 Feb 9;293(6):723-9.
Maternal and infant characteristics associated with perinatal arterial stroke in the infant.
Lee J, Croen LA, Backstrand KH, Yoshida CK, Henning LH, Lindan C, Ferriero DM,Fullerton HJ, Barkovich AJ, Wu YW.
Department of Neurology, University of California, San Francisco, CA 94117, USA.
CONTEXT: Perinatal arterial ischemic stroke (PAS) is a common cause of hemiplegiccerebral palsy. Risk factors for this condition have not been clearly defined.OBJECTIVE: To determine maternal and infant characteristics associated with PAS. DESIGN, SETTING, AND PATIENTS: Case-control study nested within the cohort of all199,176 infants born from 1997 through 2002 in the Kaiser Permanente Medical CareProgram, a managed care organization providing care for more than 3 millionresidents of northern California. Case patients were confirmed by review of brainimaging and medical records (n = 40). Three controls per case were randomlyselected from the study population. MAIN OUTCOME MEASURE: Association of maternaland infant complications with risk of PAS. RESULTS: The population prevalence of PAS was 20 per 100,000 live births. The majority (85%) of infants with PAS weredelivered at term. The following prepartum and intrapartum factors were morecommon among case than control infants: primiparity (73% vs 44%, P = .002), fetalheart rate abnormality (46% vs 14%, P<.001), emergency cesarean delivery (35% vs 13%, P = .002), chorioamnionitis (27% vs 11%, P = .03), prolonged rupture ofmembranes (26% vs 7%, P = .002), prolonged second stage of labor (25% vs 4%,P<.001), vacuum extraction (24% vs 11%, P = .04), cord abnormality (22% vs 6%, P = .01), preeclampsia (19% vs 5%, P = .01), and oligohydramnios (14% vs 3%, P =.01). Risk factors independently associated with PAS on multivariate analysiswere history of infertility (odds ratio [OR], 7.5; 95% confidence interval [CI], 1.3-45.0), preeclampsia (OR, 5.3; 95% CI, 1.3-22.0), prolonged rupture ofmembranes (OR, 3.8; 95% CI, 1.1-12.8), and chorioamnionitis (OR, 3.4; 95% CI,1.1-10.5). The rate of PAS increased dramatically when multiple risk factors werepresent. CONCLUSIONS: Perinatal arterial ischemic stroke in infants is associatedwith several independent maternal risk factors. How these complications, alongwith their potential effects on the placenta and fetus, may play a role incausing perinatal stroke deserves further study.
PMID: 15701914 [PubMed - indexed for MEDLINE]
Related Links
Maternal and infant characteristics associated with perinatal arterial stroke in the preterm infant. [Stroke. 2007] PMID:17495219
Perinatal stroke in children with motor impairment: a population-based study.[Pediatrics. 2004] PMID:15342829
Chorioamnionitis and cerebral palsy in term and near-term infants. [JAMA. 2003]PMID:14645309
Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developingcountry: unmatched case-control study. [BMJ. 2000] PMID:10797030
Predictors of outcome in perinatal arterial stroke: a population-based study.[Ann Neurol. 2005] PMID:160106591: Srp Arh Celok Lek. 2004 Oct;132 Suppl 1:49-53.
[Initial antibiotic therapy of neonatal sepsis]
[Article in Serbian]
Jesić M, Jesić M, Maglajlić S, Lukac M, Sindjić S, Vujović D, Grković S.
It is certain that in the past the types of bacterial agents responsible forneonatal sepsis and their sensitivity to antibiotics were not the same in allhistorical periods. However, the reports confirming the conclusion have beenpublished only in the last three years. According to these facts, the bacterialcauses of neonatal sepsis were analyzed in patients treated at the Universitychildren's hospital in Belgrade (S&M) as well as their sensitivity to antibioticsto determine the most effective initial therapy. Between January 2001 and June2004, 35 neonates, aged from 1-30 days, with positive blood culture were treated.Gram-negative bacteria were the cause of sepsis in 57% of patients(Pseudomonas--20%, Klebsiella--20%, E. coli--8.5%, Acinetobacter--8.5%),gram-positive in 43% (coagulase-negative Staphylococci--14%, Staphylococcusepidermidis--14%, Staphylococcus aureus--9%, Streptococcus group B--3%, Listeria monocytogenes--3%). The bacteria were the most sensitive to carbapenems (85-89%),amikacin (68%), third-generation cephalosporins (47-50%), while the sensitivityto gentamicin was less than expected (48.5%). Sensitivity to ampicillin (8%)confirmed a high level of resistance to this antibiotic. All isolatedStaphylococci were sensitive to vancomycin, and the overall methicillinresistance was 46%. Combined cefotaxime and amikacin therapy was the mosteffective of all suggested initial combinations of antibiotics (74%). Thesensitivity to all other combinations of antibiotics was 51-71%. The mostadequate initial combination of antibiotics for the treatment of neonatal sepsis is cefotaxime plus amikacin. The most adequate antibiotic for the treatment ofnosocomial neonatal sepsis is carbapenem.
PMID: 15615466 [PubMed - indexed for MEDLINE]
Related Links
Antibiotic use in neonatal sepsis. [Turk J Pediatr. 1998] PMID:9722468
[C-reactive protein concentrations during initial (empiric) treatment of neonatalsepsis] [Srp Arh Celok Lek. 2001] PMID:15637985
Neonatal septicaemia in Ilorin: bacterial pathogens and antibiotic sensitivitypattern. [Afr J Med Med Sci. 2002] PMID:12518907
Neonatal sepsis: high antibiotic resistance of the bacterial pathogens in aneonatal intensive care unit in Karachi. [J Pak Med Assoc. 2002] PMID:12481673
[Antibiotic sensitivity of bacteria isolated from the urine of children withurinary tract infections from 1986 to 1995] [Srp Arh Celok Lek. 1998]PMID:99210141: Pediatrics. 2002 Oct;110(4):673-80.
Comment in: Pediatrics. 2002 Oct;110(4):832-3. Pediatrics. 2003 Jul;112(1 Pt 1):206-7; author reply 206-7.
Clinical chorioamnionitis, elevated cytokines, and brain injury in term infants.
Shalak LF, Laptook AR, Jafri HS, Ramilo O, Perlman JM.
Department of Pediatrics, University of Texas Southwestern Medical Center atDallas, Dallas, Texas 75390-9063, USA.
OBJECTIVES: To determine the initial inflammatory cytokine response in terminfants born to mothers with clinical chorioamnionitis and to assess whether the cytokine response is associated with birth depression, abnormal neurologicexamination, and hypoxic-ischemic encephalopathy (HIE). METHODS: Infants who wereexposed to chorioamnionitis and admitted to the neonatal intensive care unit (n =61) were studied prospectively. Cytokine concentrations were measured fromumbilical cord blood and at 6 and 30 hours after birth. Control values (n = 50)were determined from cord blood of healthy term infants. Enzyme-linkedimmunosorbent assays were performed for interleukin (IL)-1beta; IL-6; IL-8;regulated on activation, normal T-cell expressed and secreted (RANTES);macrophage inflammatory protein-1alpha; and tumor necrosis factor-alpha. Serialblinded neurologic examinations using a modified Dubowitz score were performedsimultaneously at 6 and 30 hours. RESULTS: Cord IL-6 (1071 +/- 1517 vs 65 +/- 46 pg/mL), IL-8 (2580 +/- 9834 vs 66 +/- 57 pg/mL), and RANTES (95 917 +/- 16 518 vs54 000 +/- 14 306 pg/mL) concentrations only were higher in infants withchorioamnionitis versus control infants. IL-6 increased at 6 hours to 1451 +/-214 pg/mL, followed by a 5-fold decline at 30 hours in contrast to progressivedecreases over time in IL-8 and RANTES. There was no relationship betweencytokines and birth depression. Modified Dubowitz score correlated with IL-6 at 6hours (r = 0.5). Infants with HIE/seizures (n = 5) had significantly highercytokine concentrations at 6 hours versus infants without either (n = 56): IL-6(3130 vs 1219 pg/mL), IL-8 (5433 vs 780 pg/mL), and RANTES (97 396 vs 46 914pg/mL). CONCLUSIONS: There was a significant association between abnormalities inthe neurologic examination and cytokine concentrations, with the highestcytokines concentrations observed in infants who developed HIE/seizures.
PMID: 12359779 [PubMed - indexed for MEDLINE]
Related Links
Hemodynamic disturbances in premature infants born after chorioamnionitis:association with cord blood cytokine concentrations. [Pediatr Res. 2002]PMID:11861935
Amplitude-integrated electroencephalography coupled with an early neurologicexamination enhances prediction of term infants at risk for persistentencephalopathy. [Pediatrics. 2003] PMID:12563063
Interleukin-6 and interleukin-8 are elevated in the cerebrospinal fluid ofinfants exposed to chorioamnionitis. [Biol Neonate. 2005] PMID:15983435
Funisitis and chorionic vasculitis: the histological counterpart of the fetalinflammatory response syndrome. [J Matern Fetal Neonatal Med. 2002] PMID:12380603
IL-1beta, IL-6 and TNF-alpha and outcomes of neonatal hypoxic ischemicencephalopathy. [Brain Dev. 2006] PMID:16181755
