Harish Chellani

Community acquisition of β-lactamase producing Enterobacteriaceae in neonatal gut

BackgroundCommensal flora constitutes a reservoir of antibiotic resistance. The increasing variety of β-lactamases and the emergence of Carbapenem resistant Enterobacteriaceae (CRE) in community, raise concerns regarding efficacy of β-lactams. It is important to know the exact load of antibiotic resistance in the absence of any antibiotic selection pressure including via food and water.In the present study gut colonization in neonates with no direct antibiotic pressure was used as a model to evaluate β-lactam resistance in the community.ResultsIn this prospective study, 75 healthy, vaginally delivered, antibiotic naive, breast fed neonates were studied for gut colonization by Extended spectrum β-lactamases (ESBL), AmpC β-lactamases hyperproducing Enterobacteriaceae and CRE on day 0, 21 and 60. Total 267 Enterobacteriaceae were isolated and E.coli was the predominant flora. ESBL, AmpC and coproduction was seen in 20.6%, 19.9% and 11.2% isolates respectively. ESBL carriage increased threefold from day 1 to 60 showing predominance of CTX-M group 15 (82.5%), ampC genes were heterogeneous. Colonization with CRE was rare, only one baby harboured Enterobacter sp positive for kpc-2. The reservoirs for these genes are likely to be mother and the environment.ConclusionsData strongly suggests that in absence of any antibiotic pressure there is tremendous load of antibiotic resistance to β-lactam drugs. Wide spread presence of ESBL and AmpC can drive rapid emergence and dissemination of CRE. This is the first report from India which depicts the smaller picture of true antibiotic pressure present in the Indian community.

Role of probiotics VSL#3 in prevention of suspected sepsis in low birthweight infants in India: a randomised controlled trial.

Objectives To assess the effect of the probiotic VSL#3 in prevention of neonatal sepsis in low birthweight (LBW) infants. Design Randomised, double-blind, placebo-controlled trial. Setting Community setting in rural India. Participants LBW infants aged 3–7 days. Interventions Infants were randomised to receive probiotic (VSL#3, 10 billion colony-forming units (cfu)) or placebo for 30 days, and were followed up for 2 months. Main outcome measure Possible serious bacterial infection (PSBI) as per the Integrated Management of Neonatal Childhood Illnesses algorithm, as diagnosed by fieldworkers/physicians. Results 668 infants were randomised to VSL#3 and 672 to placebo. By intention-to-treat analysis, the risk of PSBI among infants in the overall population of LBW infants was not statistically significant (RR 0.79 (95% CI 0.56 to 1.03)). Probiotics reduced median days of hospitalisation (6 days vs 3 days in probiotics) (p=0.018) but not the risk of hospitalisation (RR 0.66 (95% CI 0.42 to 1.04). The onset of PSBI in 10% of infants occurred on the 40th day in the probiotics arm versus the 25th day in the control arm (p=0.063). Conclusions Daily supplementation of LBW infants with probiotics VSL#3 (10 billion cfu) for 30 days led to a non-significant 21% reduction in risk of neonatal sepsis. A larger study with sufficient power and a more specific primary end point is warranted to confirm the preventive effect of VSL#3 on neonatal sepsis in LBW infants. Trial registration number The study is registered at the Clinical Trial Registry of India (CTRI/2008/091/000049).

Pure Mesangial Proliferative Glomerulonephritis

Renal biopsies from 45 children with idiopathic nephrotic syndrome were analysed. A clinicopathologic correlation has been attempted in 19 children with mesangioproliferative glomerulonephritis. Mesan

Retinopathy of prematurity: risk factors and role of antenatal betamethasone in Indian preterm newborn babies.

Background: Increase in the survival of preterm neonates has led to increased incidence of retinopathy of prematurity (ROP). Among various risk factors, only prematurity is well-established and role of others is still not clear. Effect of antenatal betamethasone on ROP severity is also controversial. Available literature from India has a paucity of information. Objectives: (a) The primary aim of the following study is to find the incidence and risk factors of ROP and (b) secondary aim is to assess the effect of antenatal betamethasone on ROP. Design: prospective, observational cohort study. Setting: Tertiary level neonatal care unit. Materials and Methods: A total of 148 infants ≤ 34 weeks gestation at birth, completed the study protocol. Severe ROP was defined as stage II and higher (including plus disease) of ROP. Various perinatal factors including antenatal betamethasone were analyzed by univariate followed by multivariate analysis. Results: overall incidence of ROP (any stage) was 44.6%. Severe ROP was mainly detected in <1200 g birth weight and/or <30 weeks gestational age. Antenatal betamethasone was associated with non-severe form of ROP (P < 0.05) on univariate analysis, but could not pass multivariate logistic regression analysis. Among other perinatal factors studied, low birth weight (<1200 g) (odds ratio [OR]: 19.699, 95% confidence interval [CI]: 2.42-160.17, P = 0.005), low gestational age (<30 weeks) (OR: 36.52, 95% CI: 3.76-354.3, P = 0.002), acidosis (OR: 6.932, 95% CI: 1.16-41.33, P = 0.034) and blood transfusion (OR: 14.11, 95% CI: 1.494-133.5, P = 0.021) were associated with babies in severe ROP in an independent manner. Conclusions: Low birth weight and low gestational age emerged as independent significant risk factors along with blood transfusion and acidosis. Antenatal betamethasone may be preventive for severe ROP. More studies are however recommended.

VEB-1 extended-spectrum β-lactamase-producing multidrug-resistant Proteus mirabilis sepsis outbreak in a neonatal intensive care unit in India: clinical and diagnostic implications

Introduction: Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, multidrug-resistant (MDR) pathogens, are increasingly implicated in nosocomial outbreaksworldwide, particularly in neonatal intensive care units (NICUs). Proteus mirabilis is an uncommon nosocomial pathogen causing sepsis in neonates. Case Presentation: We report an outbreak of ESBL-positive MDR P. mirabilis sepsis involving five babies within 10 days in a NICU, which was promptly detected and managed. The aim of this study was to characterize the molecular mechanism of resistance to third-generation cephalosporins (3GCs) in the bacteria. Surveillance cultures were collected from health-care personnel (hand swabs, urine) and the surrounding patient-care environment. Ribotyping was performed to determine the clonality of the strain. Thirteen P. mirabilis were recovered from the blood cultures of the five babies and surveillance cultures. Twelve isolates were positive for the VEB-1 ESBL type, and were susceptible only to ciprofloxacin and carbapenems. There was an unusual phenotypic synergy observed between the 3GCs and imipenem/cefoxitin. The source of infection was traced to a contaminated multidose vial. The outbreak was associated with a high mortality (80 %). A change of empirical antibiotic policy to ciprofloxacin, with strict infection control measures, brought the outbreak to an abrupt end. Conclusion: This is believed to be the first report of a nosocomial outbreak of VEB-1 ESBL-producing P. mirabilis sepsis in neonates from India. The present report of infection due to VEB-1-producing P. mirabilis, an uncommon pathogen for an epidemic in a neonatal unit, highlights the growing significance of such Gram-negative bacteria as a cause of infections in newborns. Epidemic spread in a neonatal unit of an ESBL-producing Proteus species, which also had an intrinsically reduced susceptibility to imipenem, and resistance to colistin and tigecycline, can be a threatening situation and can result in high neonatal mortality unless recognized and controlled in a timely manner.

Sternal cleft in a neonate- repaired with silastic block and pectoralis major flaps.

Sternal Cleft is a rare variety of congenital malformation seen in neonates. It is a potentially life threatening condition that may be associated with developmental anomalies of other visceral structures. Very few cases have been reported of this condition and experience with regard to time for intervention and management is limited. The authors report a case of partial sternal cleft, without any associated anomaly that had successful outcome after surgical reconstruction.

Changing trend in bacterial etiology and antibiotic resistance in sepsis of intramural neonates at a tertiary care hospital

Background: Septicemia is an important cause of neonatal morbidity and mortality. However, organized data on causative organisms and their resistant pattern are scanty from developing countries. The changing trend in causative organisms and their antibiotic resistance is yet to be documented in India. The present study examines the trends in bacterial profile and antibiotic resistance of the organisms causing sepsis in hospitalized neonates. Materials and Methods: A retrospective laboratory-based analysis of blood cultures obtained from Neonatal Intensive Care Unit of a tertiary care hospital in New Delhi was done for the period of 1999–2014, divided into five phases. Results: A total of 4700 isolates were considered. Over time, Gram-negative organisms have replaced Gram-positives as frequent isolates. Initially, there was predominance of Klebsiella pneumoniae, then of Staphylococcus aureus which recently has been changed with coagulase negative-Staphylococcus and Acinetobacter. Growing resistance against the first and second line of drugs has been noted, including methicillin-resistant S. aureus and vancomycin-resistant Enterococcus. Conclusion: The etiological profile of neonatal sepsis has changed tremendously in the past 15 years. High resistance against common drugs necessitates continued surveillance and review of empirical antibiotic policy for neonatal sepsis. These steps are important to effectively curtail the surge of further antibiotic resistance.

Healthcare associated infections in neonatal intensive care unit and its correlation with environmental surveillance

Healthcare-associated infections (HAI) are frequent complications in neonatal intensive care units (NICU) with varying risk factors and bacteriological profile. There is paucity of literature comparing the bacteriological profile of organisms causing HAI with the environmental surveillance isolates. Therefore, this study aimed to evaluate demographic profile, risk factors and outcome of HAI in NICU and correlate with environmental surveillance. Three hundred newborns with signs and symptoms of sepsis were enrolled in the study group and their profile, risk factors and outcome were compared with the control group. Univariate analysis and multivariable logistic regression were performed. Environmental surveillance results were compared to the bacteriological profile of HAIs. We identified lower gestational age, male gender and apgar score less than 7 at 5min, use of peripheral vascular catheter & ventilator along with their duration as significant risk factors. Mortality rate was 29% in the study group (p<0.05). The HAI site distribution showed blood-stream infections (73%) to be the most common followed by pneumonia (12%) and meningitis (10%). Gram positive cocci were the most common isolates in HAI as well as environmental surveillance. The bacteriological profile of HAI correlates with the environmental surveillance report thus insisting for periodic surveillance and thereby avoiding irrational antibiotic usage.

Osteogenesis imperfecta type IIA

Osteogenesis Imperfecta Type IIA is a very rare congenital lethal form of skeletal dysplasia. We would like to highlight classical clinical and imaging features.

Gastro-esophageal Reflux: Spitting and Possetting in a Neonate

Gastro-esophageal reflux (GER) is a common occurrence in newborns and a cause of anxiety to most parents. This physiological process needs to be closely differentiated from pathological reflux. The clinical signs in infants are generally non-specific which makes the distinction difficult. The diagnostic options in infants are limited, have low sensitivity and not readily available. Treatment of GER is challenging both for the clinician and family. The mainstay of therapy involves use of conservative modalities with limited use of pharmacological agents and surgical methods. This review aims to amalgamate evidence based guidelines to our current clinical practice.