Jerzy Szczapa

Two factors of the lectin pathway of complement, l-ficolin and mannan-binding lectin, and their associations with prematurity, low birthweight and infections in a large cohort of Polish neonates.

Ficolins and one collectin, mannan-binding lectin (MBL), are the only factors known to activate the lectin pathway (LP) of complement. There is considerable circumstantial evidence that MBL insufficiency can increase susceptibility to various infections and influence the course of several non-infectious diseases complicated by infections. Much less information is available concerning l-ficolin. We report the results of a prospective study to investigate any association between either MBL deficiency or l-ficolin deficiency with prematurity, low birthweight or perinatal infections in a large cohort of Polish neonates, representing an ethnically homogenous population (n=1832). Cord blood samples were analysed to determine mbl-2 gene variants, MBL concentrations and MBL-MASP-2 complex activities (MBL-dependent lectin pathway activity) as well as l-ficolin levels. Median concentrations of l-ficolin and MBL were 2500 and 1124 ng/ml, respectively, while median LP activity was 272 mU/ml. After genotyping, 60.6% of babies were mbl-2 A/A, 35.4% were A/O and 4% were O/O genotypes. We found relative l-ficolin deficiency to be associated with prematurity, low birthweight and infections. l-Ficolin concentration correlated with gestational age and with birthweight, independently of gestational age. Preterm deliveries (<38 weeks) occurred more frequently among neonates with low LP activity but not with those having low serum MBL levels. Similarly, no association of serum MBL deficiency with low birthweight was found, but there was a correlation between LP activity and birthweight. Genotypes conferring very low serum MBL concentrations were associated with perinatal infections, and high-MBL-conferring genotypes were associated with prematurity. Our findings suggest that l-ficolin participates in host defence during the perinatal period and constitute the first evidence that relative l-ficolin deficiency may contribute to the adverse consequences of prematurity. Some similar trends were found with facets of MBL deficiency, but the observed relationships were weaker and less consistent.

Long‐term effects of diabetes during pregnancy on the offspring

Background: Many epidemiological and experimental studies have proven that some adult diseases might have their origin in fetal life. It has been also hypothesized that intra‐uterine environment in pregnancy complicated with diabetes might influence the development of obesity, type 2 diabetes, and cardiovascular diseases in the offspring.

Mannan-binding lectin genotypes and genotype-phenotype relationships in a large cohort of Polish neonates.

Circulating mannan (or mannose)-binding lectin (MBL) is genetically determined. Low MBL concentrations are associated with certain point mutations in the human MBL2 gene. Here we report the full MBL2 genotypes of 1800 Polish neonates and relate individual genotypes to serum MBL and MBL-dependent activity of the lectin pathway of complement activation. The seven acknowledged common haplotypes were found, plus the uncommon LYPD haplotype, combining to form 33 genotypes in this population. As expected, a strong correlation existed between genotypes and serum MBL or lectin pathway activity, and the latter two entities correlated strongly with each other. However, serum MBL values varied up to greater than 90-fold within genotypes. Unexpectedly, higher lectin pathway activity was found in association with the P allele relative to the Q allele. These data from a large cohort of neonates, representing an ethnically homogenous population, suggest that the current knowledge of the genetics of MBL2 is inadequate to predict serum MBL concentration and MBL-dependent lectin pathway activity in individual subjects.

Mannan-binding lectin-associated serine protease-2 (MASP-2) in a large cohort of neonates and its clinical associations.

One collectin (mannan-binding lectin, MBL) and three ficolins (M-ficolin/ficolin-1, L-ficolin/ficolin-2 and H-ficolin/ficolin-3) share the capability to activate complement via the lectin pathway. This property depends on the ability of these lectins to form complexes with MBL-associated serine proteases (MASPs), particularly MASP-2. We report the results of an investigation of cord blood MASP-2 concentrations in a large, ethnically homogeneous cohort (n=1788) of neonates. The median value of MASP-2 in cord sera was determined to be 93 ng/ml (range <25-812). Serum MASP-2 concentrations correlated with gestational age and birthweight and were significantly lower in premature babies and other pre-term babies compared with term babies. Neonates with MASP-2 concentrations below 42 ng/ml were deemed to be MASP-2 deficient. That group had a shorter mean gestational age and a higher incidence of premature and low birthweight babies, but not of perinatal infections when compared with the others. Indeed, there was a trend towards higher MASP-2 concentrations amongst babies with infections. Among 362 samples tested for the D120G single nucleotide polymorphism (SNP) of the MASP2 gene, no homozygote for that mutation was found. Heterozygosity for this allele significantly influenced the protein concentration, but not the lectin pathway of complement activity (MBL-MASP-2 complex activity). Moreover, no association of this SNP was apparent with prematurity, low birthweight or perinatal infections.

Necrotising Enterocolitis in Preterm Infants: Epidemiology and Antibiotic Consumption in the Polish Neonatology Network Neonatal Intensive Care Units in 2009

The aim of this study was to describe the epidemiology of necrotising enterocolitis (NEC), antibiotic consumption and the usefulness of microbiological tests in very low birth weight (VLBW) Polish newborns. Methods Prospective surveillance was performed in the year 2009 by local infection control teams. The study covered 910 infants hospitalized in six Polish neonatal intensive care units. Two kinds of indicators were used for the description of antibiotic usage: the duration of treatment (days of treatment, DOTs) and the defined daily dose (DDD). Results NEC incidence was 8.7% and fatality rate was 19%. Chorioamnionitis, late gestational age and low birth weight were identified as risk factors for NEC. Catheterization, mechanical ventilation and other selected procedures were used considerably longer in newborns with NEC than in the remaining neonates. Total usage of antibiotics reached 2.9 DDDs or 1.437 days; the average use of drugs per case of NEC amounted to 0.47 DDD or 23.2 DOTs. The level of antibiotic usage was analysed with correlation to microbiological tests performed and it was non-significantly greater in the group of children with NEC in whom the tests were performed. Conclusions A high risk of developing NEC is closely associated with VLBW and with inflammation of the amnion during labour. We observed no relationship between the consumption of antibiotics in neonates with NEC and positive results of microbiological testing indicating sepsis accompanying NEC or gut colonization with pathogens.

Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009–2011

BackgroundLate-Onset Bloodstream Infections (LO-BSI) continue to be one of the most important complications associated with hospitalization of infants born with very low birth weight (VLBW). The aims of this study were to assess the epidemiology of LO-BSI together with the risk factors and the distribution of causative pathogens at six Polish neonatal intensive care units that participated in the Polish Neonatology Surveillance Network from January 1, 2009 to December 31, 2011.MethodsThe surveillance covered 1,695 infants whose birth weights were <1501 grams (VLBW) in whom LO-BSI was diagnosed >72 hours after delivery. Case LO-BSI patients were defined according to NeoKISS.ResultsFour hundred twenty seven episodes of LO-BSI were diagnosed with a frequency of 25.3% and an incidence density of 6.7/1000 patient-days (pds). Results of our multivariate analysis demonstrated that surgical procedures and lower gestational age were significantly associated with the risk of LO-BSI. Intravascular catheters were used in infants with LO-BSI significantly more frequently and/or for longer duration: Central venous cathters (CVC) (OR 1.29) and Peripheral venous catheters (PVC) (OR 2.8), as well as, the total duration of total parenteral nutrition (13 vs. 29 days; OR 1.81). Occurrence of LO-BSI was significantly associated with increased the length of mechanical ventilation (MV) (OR 2.65) or the continuous positive airway pressure (CPAP) (OR 2.51), as well as, the duration of antibiotic use (OR 2.98). The occurrence of more than one infection was observed frequently (OR 9.2) with VLBW with LO-BSI. Microorganisms isolated in infants with LO-BSI were dominated by Gram-positive cocci, and predominantly by coagulase-negative staphylococci (62.5%).ConclusionsIndependent risk factor for LO-BSI in VLBV infants are: low gestational age and requirement for surgery. The incidence rates of LO-BSI especially CVC-BSI were higher in the Polish NICUs surveillance than those of other national networks, similar to the central- and peripheral utilization ratio.

The relationship between FCN2 genotypes and serum ficolin-2 (L-ficolin) protein concentrations from a large cohort of neonates.

The human FCN2 gene codes for ficolin-2 (L-ficolin), a major pattern recognition molecule and activator of the lectin pathway of complement. Seven single nucleotide polymorphisms of this gene were investigated in a large series of cord blood DNA samples. Mutations from the majority to the minority alleles at -602, -4 and +6359 were associated with an increase, while mutations at -986, -557, -64 and +6424 were associated with a decrease, in protein concentration. Full (7 loci) genotypes were obtained for 1229 unrelated neonates, 12 sets of twin siblings and one set of triplets. Forty-four separate genotypes were detected. Four genotypes accounted for more than half the unrelated neonates, and >90% had one of the 12 commonest genotypes. Genotypes were associated with significant differences in mean serum ficolin-2, but the intra-genotype concentration ranges were large and greater than the inter-genotype differences. Consequently, there were no associations between genotypes and low birthweight babies or perinatal infections, and only a weak relationship with preterm deliveries, despite all three adverse pregnancy features being significantly associated with serum ficolin-2 protein. FCN2 genotyping may be of value in clinical studies, but not as a substitute for total serum ficolin-2 protein measurement.

Early-onset infections of very-low-birth-weight infants in Polish neonatal intensive care units.

Aim: The objective of this study was to investigate the incidence, causes, the risk factors, etiologic agents and the outcomes of early-onset infections (EOIs) in very-low-birth-weight newborns in Polish neonatal intensive care units. Methods: Continuous prospective infection surveillance conducted during 2009 at 6 Polish neonatal intensive care units and included 910 newborns whose birth weight was lower than 1500 g. Infections were defined according to the Gastmeier’s criteria. EOIs were diagnosed <3 days after delivery. Results: The frequency of early-onset septicemia (EOS) was 7.0% and of early-onset pneumonia (EO-pneumonia) 8.6%. The factors significantly increasing the risk of EOS were low gestational age, small birth weight, low score in the Clinical Risk Index for Babies and Apgar score as well as maternal chorioamnionitis. The perinatal prophylaxis did not have an influence on the occurrence of EOS. The factors considerably increasing the risk of EO-pneumonia were low scores in the Clinical Risk Index for Babies and Apgar scores, a low gestational age and bacterial vaginosis in the child’s mother during pregnancy. The most important etiologic organisms were Gram-positive cocci (39.7% of all the infections, 47.8% in EOS), Streptococcus agalactiae (20% of the EOS), Gram-negative bacilli (33.3% isolates), yeast-like fungi (isolated in 7.9% of cases) and atypical bacteria (22% of the cases of EO-pneumonia). Conclusions: The observed frequency of EOS did not differ from the one described in the literature, whereas the frequency of EO-pneumonia was higher. The bacterial etiologies suggest the vertical transmission of the pathogens and a close relationship between the observed EOIs with maternal environment. The applied perinatal antibiotic prophylaxis was ineffective.

Introduction of Infant Flow nasal continuous airway pressure as the standard of practice in Poland: the initial 2-year experience.

Objective: The aim of this prospective study was to evaluate whether a change in the standard of newborn care for respiratory insufficiency by widely introducing more aggressive use of nasal continuous airway pressure (nCPAP) and including Infant Flow technology would result in satisfactory outcomes. Design: Prospectively defined analysis. Setting: Fifty-seven secondary and tertiary care neonatal centers in Poland. Patients: Patients were 1,299 newborns. Interventions: None. Measurements and Main Results: We carried out a prospectively defined analysis of 1,299 newborns included in the program between August 1, 2003, and April 30, 2005. The inclusion criterion was the occurrence of symptoms of respiratory failure irrespective of its etiology. Respiratory support was provided with the use of the Infant Flow Advance Driver. The analysis was made on data from prospectively designed questionnaires completed following each infants treatment. Infants were placed into categories based on clinical indication for use. The primary end point was avoiding tracheal intubation. A high rate of acceptance of the new practice was observed across the substantial demographic and clinical diversity of newborns. Tracheal intubation was avoided in 78% of infants treated electively with nCPAP. Of those being weaned from mechanical ventilation, 61.2% were successfully weaned. Related complications were low (1.4% pneumothorax, 12% nasal injuries). Conclusions: The new method of nCPAP with Infant Flow was adopted as standard practice in Poland. We monitored its safety and effectiveness over a 2-yr period and found it to be safe and effective as implemented. Additional research is still needed to determine the optimum patient population, strategy for use, and devices.

Enterobacteriaceae infections of very low birth weight infants in Polish neonatal intensive care units: resistance and cross-transmission.

Background: The aims of our study were analysis of the occurrence of infections by members of the Enterobacteriaceae family in 6 Polish neonatal intensive care units in 2009, their drug resistance, the epidemiology of extended-spectrum &bgr;-lactamase (ESBL)-producing strains and the possibility of using modern tools of microbiology diagnosis in infection control, especially for the reduction of antimicrobial resistance. Methods: A prospective surveillance covered 910 newborns. Case patients were defined as neonates with very low birth weight who had clinical signs of septicemia, pneumonia or necrotizing enterocolitis. Early-onset infection was defined as infection diagnosed within 3 days after delivery. Results: The incidence of Enterobacteriaceae infections was 2.6/1000 patient-days. The risk of Enterobacteriaceae pneumonia increased with the length of hospitalization (P = 0.0356). The most common pathogen was Escherichia coli (12.4% of all strains, in early-onset infection 18.5%) and Klebsiella spp. (9.1% of all). The ESBL phenotype was found in 37% of isolates, of which 89.3% were producing CTX-M-type, 70.2% TEM-type and 8.5% SHV-type. Epidemic clones were detected in the 2 studied neonatal intensive care units: 6 of the 9 ESBL-positive Enterobacter cloacae and 16 of the 18 ESBL-positive Klebsiella pneumoniae strains were classified into 1 epidemic clone, which showed resistance to penicillin without inhibitors, amoxycillin/clavulanic acid, cephalosporins, aztreoname, aminoglycosides and trimethoprim/sulfamethoxazole. Conclusions: Enterobacteriaceae bacilli are a significant problem in neonatal intensive care units, especially in early-onset infection and for long hospitalized very low birth weight infants. The observed high drug resistance was in large part related to the dominance of epidemic strains as a result of horizontal transmission. The best way to reduce drug resistance would be adequate procedures of isolation and hand hygiene.