Mamta Jajoo

Intravenous Colistin Administration in Neonates

Background: Nosocomial infection due to multidrug-resistant Gram-negative pathogens in intensive care units is a challenge for clinicians and microbiologists, and has led to resurgence of parenteral colistin use in the last decade. Safety and efficacy data regarding intravenous colistin (colistimethate) use in neonates is sparse. We present our experience of efficacy and safety of colistimethate in the treatment of sepsis in critically sick term and preterm neonates. Methods: The records of the neonates who received colistimethate in a neonatal intensive care unit of a tertiary care center from January 2009 to December 2009 were reviewed. Results: Eighteen critically sick neonates (10 term and 8 preterm) received 21 courses of colistimethate (dose ranging from 50,000 to 75,000 IU/kg/d) for treatment of pneumonia, blood stream infections, meningitis, and empyema thoracis. The isolated pathogens in decreasing order of frequency were Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonos aeruginosa, and Enterobacter. Mean duration of colistimethate was 13.1 days/course (range: 5–21 days). At least one other antibiotic was coadministered in all courses. A favorable clinical outcome occurred in 16 of 21 (76%) courses, 5 patients died due to severe sepsis with multiple organ dysfunction. Microbiologic clearance was documented in 17 courses. Increase in serum creatinine by >0.5 mg/dL above baseline in 2 babies was associated with the presence of multiple organ dysfunction syndrome in both and coadministration of netilmicin in one. Conclusions: Colistimethate intravenous administration appears to be safe and efficacious for multidrug-resistant Gram-negative infections in neonates, including preterm and extremely low birth weight neonates.

Candida tropicalis infection in a term neonate with gall bladder masses and infective endocarditis

Candida endocarditis is extremely rare in term neonates, and gall bladder involvement due to candidemia has never been reported amongst neonates and infants. A term, appropriate for gestational age neonate developed Candida tropicalis blood stream infection in second week of life. He was started on conventional amphotericin B. However, he failed to show any clinical improvement, and candidemia keep on persisting. Repeat sanctuary sites screening revealed multiple echogenic masses in heart (vegetations) and gall bladder. On changing the treatment to liposomal amphotericin B and fluconazole, he recovered clinically, echogenic masses in gall bladder disappeared, and intracardiac vegetations decreased in size.

To study the incidence and risk factors of early onset neonatal sepsis in an out born neonatal intensive care unit of India

Objectives: The objective was to study the Incidence and risk factors of early-onset neonatal sepsis in an out born neonatal intensive care unit (NICU) of New Delhi, India. Study Design and Setting: Prospective descriptive study over a period of 1 year. Patients and Methods: All out born neonates admitted within 72 h of life, with clinical features of sepsis with two or more high-risk factors for sepsis were enrolled and samples for sepsis screen and cultures were taken prior to administration of antibiotics in all cases. Standard data collection form was used to collect all demographic data and clinical characteristics of neonates. Bacterial isolates were identified, and their resistance patterns were analyzed using the Vitek 2 C system. Results : Among the 440 admissions to NICU during the study period, 82 neonates (19%) with early onset sepsis were enrolled. The mean (standard deviation) weight and hours of life at admission were 2016 ± 724.04 g and 23.05 ± 2.89 h, respectively. Incidence of early onset sepsis was 18/1000 patient. Twenty-eight (34%) neonates were home delivered. Low birth weight (68%), prematurity (46%), and poor hygiene/cord care (46%) were common risk factors while lethargy/refusal to feed (77%), hypothermia (47.5%), and respiratory distress (44%) were common clinical presentations. Sepsis screen and blood culture were positive in 57% and 18% (n = 15), respectively. Klebsiella pneumonie (36%), Staphylococcus aureus (21%), and Escherichia coli (14%) were common organisms. Case fatality rate was 14% (12/82). Conclusion: Clinical sepsis along with sepsis screen is a good marker of neonatal sepsis: Incidence of early onset sepsis varies in out born neonates and many factors affect it like place of delivery, perinatal risk factors, and immediate practices done in newborn.

A rare cause of wheezing in an infant: Esophageal duplication cyst

Esophageal duplication cyst (EDC) is classified as a subgroup of foregut duplication cyst. They are very rare and predominantly detected in children. We present an unusual cause of wheezing in a 2-month-old infant. The diagnosis of EDC was suspected by bronchoscopy, provisionally confirmed by magnetic resonance imaging, and followed by successful surgical excision of the cyst. We conclude that foregut duplication cyst of the esophagus is very rare, and must be considered in the differential diagnosis of persistent wheezing in infants who do not respond to conventional treatment.

Congenital rubella syndrome: an unusual cause of neonatal fulminant hepatic failure.

period of graft hypertrophy (fibular transfer) or callotasis consolidation (Ilizarov technique). To our knowledge, we are the first group to propose this technique, which has demonstrated successful reconstruction of large tibial defects that would otherwise require distraction osteogenesis. Our method does not intend to replace the Masquelet or other alternative techniques, but it does have a unique role in lowincome countries.

Neonatal Chikungunya during 2016 Delhi Epidemic

To the Editor: Chikungunya infection (CI), transmitted by the bite of infected Aedes mosquito (species aegypti and albopictus) is an emerging arboviral disease. A neonate can acquire infection either vertically during the perinatal period (4 d prior till 1 d after the delivery) or postnatally [1]. There is limited description of epidemiological and clinical features of postnatal CI in neonates [2–4]. This case series highlights the distinct clinical profile and outcome of neonates with postnatal CI. Out of the 10 neonates with CI, 4 were boys and 6 girls. All the neonates were born at term gestation and were exclusively breast fed. There was no history of fever in the mother during the peri-partum period or in any other family member. Neonates were admitted between 14th to 25th day of life (mean: 21.5 d). Mean weight at admission was 2.75 kg. Presenting symptoms were fever (100%), rash (100%), irritability and excessive cry (70%). Mean duration of symptoms prior to admission was 2.2 d. Examination revealed flushed appearance of skin and a rash with varied presentation. Four (40%) neonates had a diffuse erythematous maculopapular rash involving the face, limbs and trunk (sparing oral mucosa, palms and soles). Two (20%) neonates had a purpuric rash. Two (20%) other neonates had a pustular rash with abscess formation. Remaining two neonates had diffuse hyperpigmentation prominent around the perioral and trunk regions. All the neonates were extremely irritable with excessive, though consolable cry. However, there were no signs of encephalopathy or seizures. Thrombocytopenia was present in 50% cases with an average count of 65,000/mm. CRP was elevated in all the cases (mean value 24.4 ng/dl; normal <10 ng/dl). Hematocrit, total leucocyte count, renal and hepatic function tests of all neonates were normal. Sepsis screen, blood culture, urine culture and CSF examination were also normal. Malaria and dengue fever were excluded by appropriate investigations. CI was suspected due to disease endemicity and confirmed by RNA Reverse Transcriptase PCR. IgM antibodies were detected in 7 of the 10 neonates. Vertical transmission was ruled out by negative results in the mother. Fever was managed with oral paracetamol. Breast feeding was continued. Defervescence was observed within 3–5 d of admission (mean 4.6 d). Platelet counts normalised within 4–5 d. All neonates were discharged within one week of admission (mean hospital stay 5.5 d) with no residual symptoms except skin hyperpigmentation in two neonates. To summarize, CI should be suspected in the differential diagnosis of any neonate presenting with symptoms suggestive of sepsis in an appropriate setting. Early suspicion, rapid confirmation and conservative management can save the neonate from unnecessary investigations and antibiotic overuse.

A rare neurological complication of typhoid fever: Guillain-Barre' syndrome

Guillain-Barre’ syndrome is a rare complication of typhoid fever, and only a few such cases have been reported in the pediatric age group. We report a young boy with blood culture proven typhoid fever that developed this very rare neurological complication quite early in the course of the disease. Following treatment with intravenous antibiotics and intravenous immunoglobulin, he improved.

Neonatal transport: The long drive has not even begun

244 Sir, Transporting a sick newborn to an equipped health facility is a challenge in India due to scarce and inequitably distributed health facilities and underdeveloped transport network. Though in utero transport of the newborn and delivery at an adequately equipped center are ideal, a preterm delivery and all the subsequent perinatal problems cannot always be anticipated. This results in a burgeoning need to transfer such babies after birth.[1-3] Stabilization of newborn during and before transportation has been shown to improve the condition of newborn in terms of temperature, blood glucose, oxygenation, and blood pressure, thereby improving the outcome of such critically sick neonate.[4-7]

Rare case of bilirubin encephalopathy due to neonatal lupus erythematosus

Unconjugated hyperbilirubinemia is an important cause of neonatal morbidity. Here we report a case of acute bilirubin encephalopathy attributed to neonatal lupus. Transient hematologic manifestations including anemia, leukopenia, and thrombocytopenia are commonly encountered in neonatal lupus but isolated hemolytic anemia leading to severe hyperbilirubinemia in an otherwise asymptomatic newborn is an unusual presentation of neonatal lupus and to our best of knowledge not yet reported in published literature.