Prasin Chanvitan

Risk factors and outcomes of carbapenem-resistant Acinetobacter baumannii bacteremia in neonatal intensive care unit: a case-case-control study.

Background: Carbapenem-resistant Acinetobacter baumannii (CRAB) has emerged as a serious threat among critically ill neonates. Methods: We performed a case-case-control study in a Thai neonatal intensive care unit to identify risk factors and outcomes for CRAB bacteremia. Case group (CG) I was defined as cases with CRAB (n = 14), and CG II was defined as cases with carbapenem-susceptible A. baumannii (n = 38) bacteremia. The control group (n = 44) was selected from all patients admitted before and after 3 days that CG I was identified, but had no infection. Results: The mean gestational age and birth weight of CG I, II and control were 33.5, 35.2 and 35.2 weeks and 1856.5, 2273.9 and 2309.5 g, respectively. By multivariate analysis, CG I was more likely to have had an umbilical artery catheter (adjusted odds ratio = 29.30; P = 0.019) whereas CG II was more likely exposed to ceftazidime (adjusted odds ratio = 5.19; P = 0.046) and aminoglycosides (adjusted odds ratio = 35.59; P = 0.002). There was a significant difference in history of cefoperazone/sulbactam (21.4% versus 0%; P = 0.01) and imipenem use (35.7% versus 0%; P < 0.001) among CG I compared with control. Crude mortality in CG I was higher than CG II (42.9% versus 13.2%; odds ratio = 5.0; P = 0.02). Conclusion: Our cohort of neonatal CRAB bacteremia is characterized by a very high mortality. Infection-control interventions inclusive of strict adherence to infection-control process for central vascular line placement and maintenance as well as antimicrobial stewardship program are essential to help reduce CRAB bacteremia.

Maternal iodine status and neonatal thyroid-stimulating hormone concentration: a community survey in Songkhla, southern Thailand

OBJECTIVE To determine iodine intake and urinary iodine excretion (UIE) in a group of pregnant Thai women and the concentration of thyroid-stimulating hormone (TSH) in their neonates. DESIGN A prospective cohort study. SETTING Three districts of Songkhla, southern Thailand. SUBJECTS Two hundred and thirty-six pregnant women. RESULTS A quarter of the participants lacked knowledge of iodine and the prevention of iodine deficiency, although 70 % used iodized salt. Those who did not use iodized salt stated that they had no knowledge about iodine (57 %) and no iodized salt was sold in their village (36 %). The median iodine intake in the three districts was 205-240 microg/d, with 53-74 % of pregnant women having iodine intake <250 microg/d. The median UIE in the three districts was 51-106 microg/l, with 24-35 % having UIE < 50 microg/l. The mean neonatal TSH was 2.40 (sd 1.56) mU/l, with 8.9 % of neonates having TSH > 5 mU/l. CONCLUSIONS The studied women and their fetuses were at risk of mild iodine deficiency. About a quarter of the participants lacked knowledge of the importance of iodine. Education regarding the importance of iodine supplements and the promotion of iodized salt should be added to national health-care policies in order to prevent iodine-deficiency disorders, diseases that are subclinical but have long-term sequelae.

Neonatal acute kidney injury in a tertiary center in a developing country

BACKGROUND Acute kidney injury (AKI) is a common contributor to morbidity and mortality in newborns, with prevalences varying by population and hospital. A study of AKI in newborns in tertiary care centers in Thailand, a developing country with limited resources, has not been conducted yet. METHODS The aim of this study was to determine the prevalence of AKI in newborns in a tertiary care hospital in southern Thailand and to investigate the etiology, mortality and risk factors of mortality. The records of patients aged <30 days with high serum creatinine, admitted from 1984 to 2007, were retrospectively reviewed. RESULTS Eighty-eight boys and 51 girls were enrolled; 61.4% were premature and 56.5% had a birth weight <2500 g. The prevalence of newborn AKI increased from 0.9 to 6.3% during the 24-year study period. Thirty-nine and 65% had renal failure within 2 and 7 days post-birth, respectively. Sepsis was the most common cause of AKI (30.9%) followed by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart failure (12.2%) and birth asphyxia (11.5%). Indomethacin caused AKI in 24.4% with gestational age <32 weeks. Sepsis-induced AKI had the highest mortality rate (65.1%) with an overall mortality rate of 38.8% and nearly 14 times the risk of death compared to hypovolemia-induced AKI. CONCLUSIONS The prevalence of newborn AKI in our Thai tertiary center over 24 years was 6.3% of admitted newborns. Sepsis was the most common cause of AKI and sepsis-induced AKI is the most common cause of death. Disease etiology was the only risk factor for mortality.

Influence of maternal nutrient intake and weight gain on neonatal birth weight: a prospective cohort study in southern Thailand.

Objectives. To assess the nutritional intake and gestational weight gain of pregnant women and the relationship between nutritional intake, gestational weight gain, and neonatal birth weight. Methods. A prospective cohort study was carried out in three districts of Songkhla Province in southern Thailand. Nutritional intakes were calculated based on a 24-h food record and a food frequency checklist. The women were followed until delivery and the neonatal birth weight recorded. Results. Two hundred and thirty-six pregnant women with a mean age of 27.2 ± 6.2 years were recruited. The average daily energy intake was 1806 ± 482 kcal. The average gestational weight gain was 12.2 ± 4.6 kg and the average neonatal birth weight was 3054 ± 474 g. Micronutrient intakes were overall inadequate averaging only 50–80% of recommended levels. Neonatal birth weight was significantly positively correlated with gestational weight gain (r = 0.17, p = 0.01), but was not correlated with maternal nutritional intakes. Conclusions. Pregnant women in rural areas of Songkhla Province consume adequate macronutrients with appropriate gestational weight gain, but generally consume inadequate micronutrients. A nutritional education program explaining the importance of micronutrients should be a focus of a public education program.

Infectious complications in infants with gastroschisis: an 11-year review from a referral hospital in southern Thailand

UNLABELLED MAIN PURPOSES: The study aimed to (1) examine the incidence of infectious complications (ICs) in our referral hospital in southern Thailand in infants with gastroschisis, with analysis of the impact of these complications on outcomes, and (2) identify associated factors to improve the practice at our institution for dealing with this condition. METHODS A retrospective review of consecutive gastroschisis cases at the major teaching and referral hospital in southern Thailand was conducted for an 11-year period (1996-2006). Cases referred after a primary operation at other hospitals were excluded. The study focused on postoperative nosocomial infections as identified by Centers for Disease Control and Prevention criteria. RESULTS Sixty-eight patients with gastroschisis were operated on. Twenty-seven patients (39.71%) underwent primary closure. Mortality was 4 of 68 patients (5.9%). Infectious complication occurred in 43 patients (63.2%). The complications significantly increased mechanical ventilation days (10.8 vs 3.8 days in noncomplicated cases), need for parenteral nutrition (25.3 vs 14.5 days), and postoperative stay (33.7 vs 21.1 days). Common ICs were wound infection (32.35%), isolated septicemia (19.1%), and pneumonia (13.24%). Univariate analysis identified an association between the occurrence of IC and birth order (multigravida), time from birth until arrival at our center (5 hours or more), hypoalbuminemia, hypoglycemia, type of operation (staged closure), use of central venous line, and prolonged use of ventilator. On multiple logistic regression, prolonged referral time, use of a central venous line, multigravida, and staged closure independently predicted the risk of IC. CONCLUSION Infectious complication was significantly related to outcome in gastroschisis cases and should not be overlooked. Our data suggest that prompt referral, limiting central line practice on a selective basis, and an attempt to reduce wound infection in cases that require a temporary silo may improve the overall outcomes.

Effectiveness and safety of intravenous iloprost for severe persistent pulmonary hypertension of the newborn

ObjectiveThe aims of this study were to determine the effectiveness (oxygenation), safety (hemodynamic status) and short term outcomes of intravenous iloprost (IVI) administration as a rescue therapy in severe persistent pulmonary hypertension of the newborn (PPHN).DesignRetrospective medical records review.SettingTertiary neonatal intensive care unit at Songklanagarind Hospital, Songkhla Province, Hat Yai, Thailand.ParticipantsNewborns who received IVI as an adjunctive therapy for treatment of severe PPHN, as defined by an oxygen index (OI) of >20 and without response to conventional therapies.Main Outcome MeasuresThe change of OI and alveolar-arterial oxygen difference before and after commencement of IVI.Results33 neonates with severe PPHN at a median gestation of 39 weeks and a baseline OI of 40 (range, 21–101) received IVI. The median OI and alveolar-arterial oxygen difference had a statistically significant decrease after 2 hours of treatment and continued to decline thereafter (P<0.05). All infants received one or more inotropic medications and volume expanders to provide blood pressure support with no statistically significant difference of blood pressure and heart rate before and after IVI treatment. The mortality rate was 15.2%, all of them had initially severe hypoxemia with a median OI of 53.6.ConclusionsIVI may be effective in improving oxygenation and should be considered as a rescue therapy for infants with severe PPHN, especially in a limited resource environment with no inhaled nitric oxide available. Systemic hypotension may be a cause for concern.

The relationship of maternal iodine status and neonatal thyrotropin concentration: a study in Southern Thailand.

Iodine deficiency disorder (IDD) is a global health problem. Previous studies in Southern Thailand have shown that the prevalence of goiter in schoolchildren is 3-5%, indicating that Southern Thailand is an iodine sufficient area. We conducted a study in pregnant women to determine their iodine status and whether there was an association between maternal urinary iodine excretion (UIE) and the neonatal thyrotropin (TSH) concentration. We recruited 244 pregnant women attending the antenatal clinic at Songklanagarind Hospital. Their mean age was 28.5 +/- 5.3 years (range 15-42) with a mean gestation age of 9.4 +/- 2.7 weeks (range 6-15). Ten ml urine was collected for UIE measurement. All women were delivered at Songklanagarind Hospital. The mean gestational age at delivery was 38.2 +/- 2.1 weeks (range 28-41). The median maternal UIE was 139.5 microg/l with 78 (32%) women having UIE below 100 microg/l. The median TSH of the infants was 4.14 mIU/l (range 0.30-17.89) with 88 (36.1%) of infants having TSH concentration above 5 mIU/l. Logistic regression analysis revealed that the odds ratio of pregnant women with UIE below 100 microg/l giving birth to infants with neonatal TSH above 5 mIU/l was 2.04 (95% confidence interval 1.17-3.66, p = 0.012). In conclusion, our findings demonstrate that 32% of pregnant women have UIE below 100 microg/l, and that UIE below 100 microg/l in pregnant women is associated with neonatal TSH concentration above 5 mIU/l. These findings suggest that iodine deficiency is prevalent in pregnant women in Southern Thailand.

Congenital Hepatic Arteriovenous Malformation Presenting with Severe Persistent Pulmonary Hypertension

Congenital hepatic arteriovenous malformation is a rarely seen vascular malformation with persistent pulmonary hypertension in neonates. The authors report a full-term female newborn presenting with intractable heart failure and respiratory distress soon after birth. Investigation by echocardiography showed severe persistent pulmonary hypertension of the newborn and patent ductus arteriosus. The hepatic angiogram revealed congenital hepatic arteriovenous malformation; therefore, secondary pulmonary artery hypertension complicated with ‘steal’ phenomenon was conclusively diagnosed.

Brief communication (Original). Trends in neonatal sepsis in a neonatal intensive care unit in Thailand before and after construction of a new facility

Abstract Background: Neonatal sepsis is a cause of mortality and long-term morbidity worldwide. Objectives: To describe longitudinal trends in the cumulative incidence of early- and late-onset sepsis (EOS and LOS), mortality, and causative organisms in a Thai Hospital before and after construction of a new neonatal intensive care unit (NICU). Methods: Review of NICU admissions with blood cultures positive for bacteria or fungi for the periods 1995 to 2002 (preconstruction) and 2004 to 2010 (postconstruction). Sepsis was categorized into EOS (within first 3 days of life) and LOS (after first 3 days of life). Results: Of 5,570 admissions, 241 (4.3%) neonates with 276 episodes of sepsis were identified. There was no difference in the rate of sepsis overall (P = 0.90), LOS (P = 0.30), or sepsis-related mortality (P = 0.61) over the two periods, but the rate of EOS increased significantly from 0.34% to 0.81% (P = 0.04). Rates of Klebsiella species and Escherichia coli sepsis increased from 13.6% to 25.6% (P = 0.01) and from 5.3% to 12.2% (P = 0.04), respectively, while rates of Staphylococcus aureus sepsis decreased from 12.9% to 4.3% (P < 0.007). Sepsisrelated mortality was 1.8%. Conclusions: Although direct causality cannot be proven, the rate of EOS and the pattern of causative organisms changed following construction of the new NICU. Building a new unit does not necessarily result in a reduction in the rate of sepsis. This data may provide a baseline for implementing evidence-based infection control strategies to prevent/reduce sepsis and improve neonatal care.

Sutureless elastic ring silo for the gastroschisis.

Abstract Background: The definitive surgical management of gastroschisis is the return of the eviscerated abdominal content into the abdomen as soon as possible. Objectives: Assess the efficacy of using a sutureless elastic ring silo (SERS) for the management of gastroschisis. Methods: Neonates with gastroschisis were enrolled at Songklanagarind Hospital between January 2006 and December 2008. A primary repair (PR) was attempted in all cases. If this was not possible due to concerns about abdominal compartment syndrome, a stage abdominal closure with a silo pouch was fashioned: a traditional silo (TS) or SERS. When the bowel was completely reduced, a second-stage closure was performed in the operating room. Data collected included general demographic data, size of defect, associated anomalies, hospital course, mode of gastroschisis closure, duration of parenteral nutrition (PN) and ventilator, first feeding age, complications, and length of hospital stay (LOS). Results: Twenty-nine children with gastroschisis were treated (PR: 9, TS: 9, and SERS: 11). There were no differences (p >0.05) concerning gender, mode of delivery, APGAR scores, gestational age, birth weight, or defect size. A preformed silo was employed in 20 of 29 cases, TS in nine (31%), and SERS in 11 (38%) cases in an average operative time of 80.6 and 40 minutes, respectively, a significantly shorter operative time in the SERS (p =0.007). Overall, there were no differences (p >0.05) concerning duration of ventilator support (10.2 days), duration of PN (21.3 days), first feeding age (15 days), LOS (26.5 days), and complication. Conclusion: The use of a sutureless elastic ring silo with readily available inexpensive materials is simple, safe and efficacious in our setting.