Oreste Battisti

Changing blood culture isolates in a referral neonatal intensive care unit.

An analysis was made of all cases of bacteraemia that had occurred in the referral neonatal intensive care unit at Hammersmith Hospital during the years 1976--79. One hundred and thirteen infants had positive blood cultures; 27 were born in the hospital, and 86 admitted from elsewhere. This gave a rate of 5.7/1000 live hospital births, and 165/1000 outborn admissions to the unit. The latter infants were predominantly of very low birthweight or were ill. Thirty-three of the isolates were cultured in the first 48 hours of life (early) and the remaining 80 after that time (later). Staphylococcus epidermidis was the organism most often isolated both early and later. These results were different from those recorded in the previous 9 years (1967--75) from the same unit. Then, group B beta-haemolytic streptococcus was the organism most often isolated early, while Gram-negative bacteria predominated among later isolates. The changing nature of care may contribute to these findings.

Adaptation in Neonatology of the Once-Daily Concept of Aminoglycoside Administration: Evaluation of a Dosing Chart for Amikacin in an Intensive Care Unit

BACKGROUND The bactericidal efficacy of aminoglycosides is directly related to peak serum concentration (Cmax), particularly the first one. Transitory high concentrations of aminoglycosides do not result in such a high drug uptake by renal and cochlear tissues because of the saturation of cell binding sites. These observations have led to the concept that less frequent administration of relatively larger doses of aminoglycosides would be of interest in treating infectious diseases. OBJECTIVE Prospective evaluation of a dosing chart of amikacin (Ak) in high-risk neonates suspected of infection within the first 2 days of life. This dosing chart was based on a previous pharmacokinetic population study published elsewhere, treated accordingly to the new once-daily concept of aminoglycoside administration. STUDY DESIGN One hundred and seventy-seven neonates (69 females and 108 males; mean gestational age (GA +/-SD: 33.6 +/- 4.1 weeks (W) received Ak regimen dosage according to the following dosing chart: Group (Gr) 1a GA <28 W: 20 mg/kg/42 h; Gr 1b GA 28 </= 31 W: 20 mg/kg/36 h; Gr 2 GA 31 </= 34 W: 18.5 mg/kg/30 h; Gr 3 GA 34 </= 37 W: 17 mg/kg/24 h; Gr 4 GA >/= 37 W: 15.5 mg/kg/24 h. In case of asphyxia, hypoxic episode and intercourse treatment with indomethacin, the interval was systemically increased by 6 h whatever the GA groups. The mean duration time of Ak treatment (+/- 1 SD) was 5.00 +/- 2.01 days (range 2-13). Ak serum concentrations 1 h after completion of 30 min infusion (C1h), and successive Ak serum concentrations just before next administration depending on the difference of interval between each group (so defined minimum serum concentration (Cmin)), were determined in each neonate. Creatininemia during the fist postnatal weeks was used as an index of glomerular filtration rate; brainstem auditory evoked potentials (BEAPs) were used in 139 babies when reaching a postconceptional age of >/= 36 weeks to assess possible ototoxicity, and were compared to values from a group of term and a group of preterm babies, previously defined as our reference control groups. RESULTS At day 1 of treatment, there was no correlation between the Ak C1hS and the GA at birth (mean 27.8 +/- 5.21 microgram/ml (+/- 1 SD); median 28; r = -0.003; range 10-40). In the same way, there was no correlation between the first Ak CminS and the GA at birth (mean 3.7 +/- 2.0 microgram/ml (+/- 1 SD); median 3.0; r = -0.33; range 0-10). The lack of correlation between these first observed C1hS and CminS and the GA at birth suggests the validity of our previous established dose regimen recommendations. Analyzing the data between groups, the mean value +/- 1 SD of Ak C1hS at day 1 of treatment was not significantly different (p > 0.05). Concerning the first Ak CminS, a significant difference (p < 0.01) was only observed when comparing groups 1a, 1b and 2 to group 4. However, this significant difference disappeared when comparing the successive next Ak CminS between groups while each interval remained the same, suggesting a positive postnatal maturation of the renal clearance. In the same way, creatininemia showed a significant and normal decrease (p < 0.01) in each group during the first postnatal weeks. Threshold values of BEAPs at 30 dB showed no significant difference (p > 0.05) between the treated groups (preterm group and term group) and the corresponding control groups. While the primary aim of the study was not to test the bactericidal efficacy of this new regimen, the recovery was excellent in 37 babies with proven or highly suspected infectious disease, except in 1 of them who died from septic shock (group B Streptococcus). After 5 years of using this kind of Ak administration in the unit, minimal inhibitory concentration profiles tested in 43 successive bacterial strains collected from inborn patients remained adequate. (ABSTRACT TRUNCATED)

A scoring system in predicting the risk of intestinal stricture in necrotizing enterocolitis

Of 46 infants with a diagnosis of necrotizing enterocolitis (NEC) admitted to the neonatal intensive care unit over the period 1981–1985, 40 have been followed from 2 to 6 years after the acute episode. A contrast enema (CE) to look for intestinal strictures (IS) was performed either during the first months in surgically managed patients, or between 2 and 6 years in asymptomatic patients. Clinical, laboratory and radiology parameters collected during the 7 days following NEC were used to establish a score which was correlated with radiological data obtained after CE. Of the 40 infants, 17 developed symptomatic or asymptomatic IS and 16 of these 17 infants has a score ≥7. Nineteen of the 23 patients without IS had a score <7. We conclude that the proposed score established on day 8 after onset of NEC helps to identify infants at higher risk of developing IS and for whom closer follow up appears necessary.

Aminoglycoside nephrotoxicity and urinary excretion of N-acetyl-beta-D-glucosaminidase

The purpose of this paper is to discuss briefly the mechanism of aminoglycosides nephrotoxicity. This kind of antibiotic seems to act preferentially on the phospholipid metabolism of the proximal tubular cell. A lysosomal enzyme, N-acetyl-beta-D-glucosaminidase, could be of interest in assessing this renal interference.

Digoxin-like immunoreactive substance in serum of preterm and full-term neonates

A significant serum level of digoxin-like immunoreactive substance (DLIS) (≥0.5 ng/ml) has been found in healthy full-term neonates, in prematurely born neonates as well as in full-term but small for gestational age neonates. Neither the babies nor their mothers had received digoxin therapy. On the first day of life, the incidence of serum levels of DLIS≥0.5 ng/ml in the three groups of neonates were respectively 64% (32/50), 42% (8/19) and 77% (10/13). Longitudinal measurements in preterm and small for gestational age neonates indicate a progressive disappearance of DLIS from their serum, none of them having a significant serum level at 21 days of age. As long as the chemical structure, origin and physiological properties of DLIS remain unknown, clinicians must be cautious in interpreting the serum levels of digoxin used for therapeutical purpose in neonates.

Normal values for urinary N-acetyl-beta-glucosaminidase excretion in preterm and term babies.

Urinary N-acetyl-beta-glucosaminidase (NAG) excretion was measured in 14 healthy, preterm, male neonates with gestational ages between 32 and 35 weeks. Daily NAG excretion increased significantly during the first four weeks of life. No correlation was observed between urinary NAG:creatinine ratio and postnatal age regardless of whether measurements were taken from the whole 24 hour urine collection or from an isolated urine spot sample at the same time on each day. When the preterm infants were compared with a group of 20 healthy, full term, male infants at a postnatal age of 7 days the NAG:creatinine ratio was significantly higher in the preterm group, the measurements having been taken from single urine spot samples. We suggest that this variable be used in the evaluation of renal tubular integrity during the neonatal period.

Validity of N-acetyl-beta-D-glucosaminidase (NAG) determination in assessing netilmicin nephrotoxicity in preterm babies

The supposed nephrotoxicity of netilmicin has been assessed in preterm neonates using the urinary excretion of a lysosomal enzyme as marker: N-acetyl-beta-D-glucosaminidase (NAG). 17 male preterm neonates with birth weight appropriate for gestational age were enrolled in a study where 9 received netilmicin therapy since the first day of life and 8 served as control group. We observed a significant increase in urinary NAG/creatinine ratio during the postnatal days in the netilmicin group babies followed by a regular decrease during the days after the end of therapy. If this increase in lysosomal enzymuria such as NAG could reflect netilmicin nephrotoxicity on the proximal tubular cell, many questions remain unanswered about the exact significance of this finding. In particular, its relation with tubular cell dysfunction remains to be established.

Phosphorus intake in preterm babies and variation of tubular reabsorption for phosphate per liter glomerular filtrate

Inadequate low intake of phosphorus can induce a hypophosphatemic depletion syndrome resulting in hypercalcemia, hypercalciuria, hypophosphatemia, and rickets. Tubular reabsorption for phosphate per liter glomerular filtration rate (TP/GFR) has been proposed as a reliable index of renal phosphate handling for all age groups. In the present study, carried out in 12 healthy premature babies fed unmodified pooled human milk and then a preterm formula for two periods of 10 days, we demonstrated clearly that TP/GFR as well as calciuria can reflect the poor phosphorus intake and that the kidney of preterm babies is able to rapidly adapt itself to an increase in phosphorus diet content.

Mortality in 504 infants weighing less than 1501 g at birth and treated in four neonatal intensive care units of South-Belgium between 1976 and 1980

Mortality was studied in 504 infants weighing less than 1501 g at birth and treated in four neonatal intensive care units of South-Belgium between 1976 and 1980. Two hundred and twenty-one babies died during their stay at the hospital, a mortality rate of 438 per 1000 live births. The neonatal mortality rate (mortality during the first 28 days of life) was 373 per 1000 live-births. Thirty-three infants died after the neonatal period, which is 15% of the total number of deaths. Twothirds of these post-neonatal deaths were related to complications of diseases associated with pre-term delivery. Mortality rates were higher in infants of less than 1001 g than in those of 1001–1250 g or 1251–1500 birth weight. In each birth weight category, patients born in their own obstetrical departments and referred infants had similar mortality rates. Longitudinal analysis showed improving mortality rates between 1976 and 1977 in the total population of VLBW infants, between 1977 and 1978 in infants of <1001 g and in 1980 compared to 1976 in the 1251–1500 g group. There were higher incidences of need for ventilatory assistance, patent ductus arteriosus, necrotising enterocolitis and septicaemia in referred patients of <1001 g than in patients born in their own obstetrical departments with comparable birth weight. Artification ventilation was more often required in referred infants of 1251–1500 g. This study confirms the importance of considering at least the complete hospital stay when analysing mortality in VLBW infants. Infants of <1001 g had high mortality, particularly after the neonatal period. This phenomenon was asscciated with complications of morbid conditions related to extreme prematurity.

Le prématuré confronté aux troubles de l'attachement parents-enfant. Prévention et prise en charge

Summary remature birth is a factor of impaired infant-parent attachment. In addition it is frequently associated with other factors of impaired attachment related either to the infant (mainly the various pathologies of the premature infants and the hospitalization) and/or to the parents, specially the mother. The main characteristics of the normal process of infant-parent interaction are described as a basis for the early recognition and assessment of impaired interaction and preventive intervention.