Ballambattu Vishnu Bhat

Asymptomatic colonization of upper respiratory tract by potential bacterial pathogens

ObjectiveTo screen for asymptomatic respiratory carriage of S. pneumoniae, H. influenzae and Group A Streptococcus (GAS) in children attending JIPMER, correlate carriage rate with different socio-demographic factors and to detect antimicrobial resistance among the isolates.MethodsThroat swabs were collected from both in patients and out patients (≤12 yr of age) and processed. Bacteria were identified by Standard techniques. Susceptibility to commonly used antimicrobial agents was determined by Kirby Bauer disc diffusion technique.ResultsOverall carriage rate of respiratory pathogens was 30% with S. pneumoniae, H. influenzae and GAS accounting for 22%, 5% and 4.5% respectively. Three patients had >1 organism. Antibiotic resistance was highest in S. pneumoniae with 66.7% of strains resistant to penicillin. MDR strains were also encountered. Erythromycin resistance was observed in both H. influenzae (28.4%) and GAS (22%). No statistically significant association was found between the carriage rate of these organisms and different socio-demographic factors.ConclusionsS. pneumoniae carriage rate was comparatively higher in the Community and its antimicrobial resistance is an issue to address.

Growth pattern of low birth weight babies in the first year of life.

Objective: The growth pattern of low birth weight (LBW) babies was studied prospectively in our hospital from September 1995 to august 1996.Method: Every baby <1.5 kg birth weight (B.Wt), every 2nd baby between 1.5 to 2 kg, every 6th baby between 2to 2.5 kg and 120 term appropriate for gestation (AGA) babies ( as controls) were included in the study. Severe birth asphyxia, multiple gestation, major malformations or severe birth trauma formed exclusion criteria. Weight, length and head circumference were measured in all babies at birth and at 2 monthly intervals till 1 year of age. All babies completing 1 year follow-up were included for final analysis. Growth distance curves were constructed separately for each parameter for the six categories based on birth weight (Groups I-VI) and on gestational age (Divisions A-F). Comparison was made between the LBW babies and the controls for growth pattern among the babies who completed 1 year follow up (total of 220 babies).Result: The growth pattern for weight and length showed good catch up growth in babies >1.25 kg B.Wt. and >30 weeks gestation, reaching almost the same level as controls by 1 year of age. Babies with B.Wt <1.25 kg and <30 weeks gestation showed late and poor catch up growth, with considerable lag persisting at 1 year of age. Head circumference increased rapidly in all babies, with maximal growth rate initially followed by a steady decline. All babies showed catch up growth, although those <1.25 kg and <30 weeks gestation still lagged behind even at 1 year.Conclusion: It was seen that the smallest and least mature babies had late and poor catch up growth. Recognition of the factors influencing catch up growth and adequate measures to improve growth (like attention to feeding practices) may improve the overall outcome of these babies.

Efficacy of zinc supplementation on serum calprotectin, inflammatory cytokines and outcome in neonatal sepsis - a randomized controlled trial.

Abstract Objective: To find out the efficacy of zinc supplementation in decreasing the levels of serum calprotectin and inflammatory cytokines with improvement in outcome in neonatal sepsis. Methods: Neonates with clinical signs suggestive of sepsis and at least two screening tests positive were randomized into two groups – zinc group and control group. The zinc group received 3 mg/kg of zinc sulfate monohydrate twice a day orally for 10 days along with antibiotics. The control group received antibiotics and supportive care. Serum zinc, calprotectin, TNF-α and IL-6 were estimated in serum at recruitment and 10 days later after completion of antibiotics. The babies were monitored daily till discharge and mortality rate was compared between the groups. Results: Baseline characteristics were similar between the groups. Serum zinc levels were considerably increased in the zinc group after supplementation. There was significant decline in concentrations of serum calprotectin, TNF-α and IL-6 (p < 0.05) in the zinc group. In the control group also, serum calprotectin and IL-6 levels were found to be decreased significantly after antibiotic treatment (p < 0.05), while TNF-α showed insignificant reduction. Kaplan–Meier analysis was performed to assess the survival time between the groups. The mortality was lower in the zinc group compared to the control group 5 versus 11, p= 0.12. Conclusion: Neonates with sepsis who received zinc in addition to antibiotics showed significant reduction in serum calprotectin and inflammatory cytokines. Although mortality was lower in zinc group, it was not statistically significant.

Current Concepts in the Management of Meconium Aspiration Syndrome

In developing countries, meconium aspiration syndrome (MAS) is an important cause of morbidity and mortality among neonates. The concepts of pathophysiology and management of meconium stained amniotic fluid (MSAF) and meconium aspiration syndrome have undergone tremendous change in recent years. Routine intranatal and postnatal endotracheal suctioning of meconium in vigorous infants is no longer recommended. Recent studies have challenged its role even in non-vigorous infants. Supportive therapy like oxygen supplementation, mechanical ventilation and intravenous fluids are the cornerstone in the management of meconium aspiration syndrome. Availability of surfactant, inhaled nitric oxide, high frequency ventilators and extracorporeal membrane oxygenation has made it possible to salvage more infants with meconium aspiration syndrome. In this review the authors have discussed the current concepts in the pathophysiology and management of MAS. Drugs in trials and future therapeutic targets are also discussed briefly.

Innate Immunity at Birth: Implications for Inflammation and Infection in Newborns

Abstract The development of immunity at birth is vital and it involves several complex mechanisms. Since prior antigenic experience is limited, the adaptive immunity requires time for development. The newborns depend heavily on their innate immunity for survival during early life. The microbiome with the commensal flora contributes to the development of immunity in newborns. Maternal antibodies at the various mucosal surfaces are the primary checkpoints which provide immunity in the neonatal period. The reduced chemotaxis, phagocytosis and sustained activation of neonatal neutrophils and monocytes increase the susceptibility of newborns to infection. The quantitative and qualitative characteristics of dendritic cells are subset specific and their varied ontogeny and functions impair antigen presentation and reduce the vaccine responsiveness in early life. The natural killer cell functions like degranulation and release of lytic factors are reduced in early life which makes the newborns more prone to viral infections. Dietary limitation during lactation has shown to modify the functions of immune cells and increase the susceptibility to pathogenic invasion. Dietary supplements like lactoferrrin have shown to increase the levels of immunoglobulins and improve the mucosal and systemic immune response in early life.The development of immunity at birth is vital and it involves several complex mechanisms. Since prior antigenic experience is limited, the adaptive immunity requires time for development. The newborns depend heavily on their innate immunity for survival during early life. The microbiome with the commensal flora contributes to the development of immunity in newborns. Maternal antibodies at the various mucosal surfaces are the primary checkpoints which provide immunity in the neonatal period. The reduced chemotaxis, phagocytosis and sustained activation of neonatal neutrophils and monocytes increase the susceptibility of newborns to infection. The quantitative and qualitative characteristics of dendritic cells are subset specific and their varied ontogeny and functions impair antigen presentation and reduce the vaccine responsiveness in early life. The natural killer cell functions like degranulation and release of lytic factors are reduced in early life which makes the newborns more prone to viral infections. Dietary limitation during lactation has shown to modify the functions of immune cells and increase the susceptibility to pathogenic invasion. Dietary supplements like lactoferrrin have shown to increase the levels of immunoglobulins and improve the mucosal and systemic immune response in early life.

Clinical Profile and Outcome of Serratia Infection among Neonates

To the Editor : Outbreaks due to Serratia marcescens in neonatal intensive care units (NICUs) have been reported across the globe and these coccobacilli have contributed to 15 % of nosocomial infections in NICUs [1]. Contaminated hands of healthcare personnel, breast pumps, parenteral solutions and respiratory equipment are likely modes of transmission [2]. Colonized and infected infants are important reservoirs of S. marcescens and gut colonization can persist longer [3]. A descriptive study was done over 2 mo in a level III NICU of south India to describe the clinical profile and outcome of neonates with culture proven Serratia sepsis and compare it with that of gestational age matched neonates with sepsis due to other microorganisms. Out of 2819 neonates delivered during 2 mo, 663 were admitted to NICU. Among these neonates, 114 had culture proven sepsis and out of these 34 (30 %) had sepsis due to Serratia. The other organisms isolated were Enterococcus in 18 (16 %), Enterobacter in 15 (13 %), Klebsiella in 23 (20 %), Coagulase negative staphylococci in 8 (7 %), Staphylococcus aureus in 4 (4 %), E. coli in 10 (8 %) and Pseudomonas in 2 (2%). Among the 34 neonates with Serratia sepsis, respiratory distress (88 %), shock (50 %), capillary leak (41 %), seizures (38 %) and sclerema (32 %) were noted. Anemia and thrombocytopenia were present in 74 and 56% neonates respectively and required mechanical ventilation. Eleven neonates (32 %) died. Factors associated with Serratia sepsis were prematurity, low birth weight, prolonged hospital stay and mechanical ventilation. These factors are also associated with sepsis caused by other organisms. The ability of S. marcescens to produce a beta-lactamase confers resistance to broad-spectrum beta-lactam antibiotics and hence controlling Serratia outbreaks may become difficult. Carbapenemase producing S. marcescens has been reported from Argentina [4]. In our study, empirical therapy with meropenam and cefoperazone with sulbactam were found to be useful. Overcrowding of neonates in our NICU could be a cause for the increased incidence of sepsis including Serratia. This study also reiterates the need for continued surveillance and strengthening nosocomial infection preventive strategies in NICUs. Two or more temporally related cases of nosocomial S. marcescens infection should raise the suspicion of an outbreak, particularly in the NICU [5]. Awareness regarding this emerging pathogen should percolate among the healthcare personnel involved.

Improving neonatal survival in India

Every year an estimated four million babies die in the fi rst 4 weeks of life and 75% of neonatal deaths occur in the fi rst week.[1] More than a quarter of global neonatal deaths occur in India.[2] India has achieved signifi cant reduction in the infant mortality rate from 81 deaths per 1,000 live births in 1990 to 47 deaths per 1,000 live births in 2011. However, there is small or no decline in the neonatal mortality rate (NMR), which is still as high as 29 per 1,000 live births.[3,4] This stagnation of neonatal mortality in India highlights the importance of improving the quality of perinatal as well as neonatal care. It is very obvious that the Millennium Development Goal 4, which stipulates a two-third reduction in underfive mortality by 2015, cannot be achieved without ensuring a substantial reduction in the NMR.

Assessment of oxidative stress in babies under phototherapy for neonatal jaundice

Background: Neonatal jaundice is a common condition that can be treated with phototherapy. Phototherapy may cause oxidative stress in addition to the usual side effects. Aim: In this study, the oxidative stress in babies with neonatal jaundice was assessed before and after phototherapy by estimating plasma malondialdehyde (MDA) level. Methods: Eighty babies with neonatal jaundice were chosen for the study. Among them, 40 babies whose total serum bilirubin level was >15 mg/dl formed the case group and the other 40 babies with total serum bilirubin level <15 mg/dl who did not require phototherapy formed the control group. Total serum bilirubin was measured using Automated Clinical Chemical Analyser with standard reagent kit. Plasma MDA was estimated by Satoh′s method using spectrophotometry. Results: The plasma MDA level, which is one of the oxidant markers, was significantly elevated in post-phototherapy cases compared to pre-phototherapy and controls. Conclusion: Phototherapy results in significant oxidative stress among babies with neonatal hyperbilirubinemia. So, usage of phototherapy should be restricted to those with significant hyperbilirubinemia.

Sepsis genomics: Stepping forward toward sepsis prevention?

The era of personalized medicine has already begun and now it is time to initiate personalized prevention strategies against diseases. Infectious diseases have a higher mortality than any other illness, especially in developing countries. Among newborns and young children the situation is even worse. The microorganisms are becoming resistant to almost all known antibiotics. Hence, it is imperative to improve the preventive strategies against infections. ′Pathogens are everywhere, but not every individual is getting diseased,′ - this basic logical thinking needs to look into the genetic predisposition/host susceptibility to sepsis. Interestingly, genetic studies have shown that the type of infecting organism, outcome of infections, and mortality can be predetermined by analyzing an individual′s genome. Exploration of inter-individual genetic variations and their association with sepsis will help in the development of new prognostic markers to provide novel personalized therapeutics and predict the outcome. In this review article, we discuss the genetic variations and their association with sepsis, studied by various researchers in different regions.