Reinhard Berner

Enterococcal colonization of infants in a neonatal intensive care unit: associated predictors, risk factors and seasonal patterns

BackgroundDuring and shortly after birth, newborn infants are colonized with enterococci. This study analyzes predictors for early enterococcal colonization of infants in a neonatal intensive care unit and describes risk factors associated with multidrugresistant enterococci colonization and its seasonal patterns.MethodsOver a 12-month period, we performed a prospective epidemiological study in 274 infants admitted to a neonatal intensive care unit. On the first day of life, we compared infants with enterococcal isolates detected in meconium or body cultures to those without. We then tested the association of enterococcal colonization with peripartal predictors/risk factors by using bivariate and multivariate statistical methods.ResultsTwenty-three percent of the infants were colonized with enterococci. The three most common enterococcal species were E. faecium (48% of isolates), E. casseliflavus (25%) and E. faecalis (13%). Fifty-seven percent of the enterococci found were resistant to three of five antibiotic classes, but no vancomycin-resistant isolates were observed. During winter/spring months, the number of enterococci and multidrug-resistant enterococci were higher than in summer/fall months (p = 0.002 and p < 0.0001, respectively). With respect to enterococcal colonization on the first day of life, predictors were prematurity (p = 0.043) and low birth weight (p = 0.011). With respect to colonization with multidrug-resistant enterococci, risk factors were prematurity (p = 0.0006), low birth weight (p < 0.0001) and prepartal antibiotic treatment (p = 0.019). Using logistic regression, we determined that gestational age was the only parameter significantly correlated with multidrug-resistant enterococci colonization. No infection with enterococci or multidrugresistant enterococci in the infants was detected. The outcome of infants with and without enterococcal colonization was the same with respect to death, necrotizing enterocolitis, intracerebral hemorrhage and bronchopulmonary dysplasia.ConclusionIn neonatal intensive care units, an infants susceptibility to early colonization with enterococci in general, and his or her risk for colonization with multidrug-resistant enterococci in particular, is increased in preterm newborns, especially during the winter/spring months. The prepartal use of antibiotics with no known activity against enterococci appears to increase the risk for colonization with multidrug-resistant enterococci.

Is serum procalcitonin a reliable diagnostic marker in children with acute respiratory tract infections? A retrospective analysis

IntroductionAcute respiratory tract infections (ARI) in children are often treated with antibiotics even without evidence of bacterial infection. Serum procalcitonin (PCT) is elevated in bacterial but not in viral infections.Patients and methodsWe performed a retrospective analysis of children in the PID-ARI.net study on respiratory infections to address the question of whether plasma PCT could potentially distinguish between bacterial infections requiring antibiotic therapy and viral ARI. We analysed data on 327 children who had been included in the German PID-ARI.net study and in whom nasopharyngeal aspirates had been analysed with a 19-valent multiplex reverse transcription-polymerase chain reaction–enzyme-linked immunosorbent assay for viral and atypical bacterial pathogens. Serum PCT was determined using a quantitative immunoassay (BRAHMS Kryptor PCTsensitive, Henningsdorf, Germany). We then focussed specifically on those children who were treated with antibiotics and therefore had been suspected of having bacterial infection but who had a serum PCT level lower than 0.1xa0ng/ml.ResultsOut of 327 children, 132 had serum PCT levels below 0.1xa0ng/ml. Of these 132, 38 children had been treated with antibiotics. After exclusion of 26 patients (with critical illnesses, antibiotics on admission or for reasons other than ARI), 12 children remained for further evaluation. Of these 12 children, four had atypical pneumonia; four others had positive virus testing, and, in the last four, the aetiology of ARI remained unknown; evidence of bacterial infection could not be detected in any.ConclusionsTaken the results of this retrospective analysis, serum PCT values below 0.1xa0ng/ml might be a marker to identify children with acute respiratory tract infection in whom antibiotic treatment could be withheld. However, only a prospective intervention trial will prove the general safety of this limit.

Secular trends in pediatric bloodstream infections over a 20-year period at a tertiary care hospital in Germany

ObjectiveOver the last 20xa0years, a number of medical innovations with impact on the incidence of bacterial and fungal bloodstream infections (BSIs) in children have been developed and implemented. Although appropriate empirical antimicrobial therapy is a prerequisite to the successful treatment of BSIs, to date, epidemiological data on long-term microbiological trends in BSIs of hospitalized children have not been available.MethodsTwo cohorts of pediatric patients who were hospitalized in a single-center tertiary care hospital in Germany over a 20-year time span (period A from 1985 to 1995 vs. period B from 1997 to 2006) were retrospectively analyzed and compared with respect to the epidemiology and microbiology of BSIs.ResultsA total of 1,646 cases of monomicrobial BSIs were detected. The rate of positive blood culture results dropped from 4.5% in period A to 2.0% in period B. The proportion of gram-positive vs. gram-negative pathogens recovered from blood cultures remained stable. Among gram-positive pathogens, an increase in enterococci (3.3% vs. 8.2%) and in coagulase-negative staphylococci (CoNS) (22.9 vs. 28.2%) was observed. In contrast, BSIs caused by Staphylococcus aureus (16.4% vs. 11.7%), Streptococcus agalactiae (4.9% vs. 2.1%), Haemophilus influenzae (7.3% vs. 0.7%), and Neisseria meningitidis (1.9% vs. 0.5%) diminished. In analyzing subgroups, an increase of enterococcal and CoNS infections was noted among patients with immunosuppression and neonatal early-onset sepsis (EOS), while a decrease was found among late-onset sepsis (LOS) cases with S. viridans. Notably, aminopenicillin-resistant enterococci and aminopenicillin- and fluoroquinolone-resistant Enterobacteriaceae all increased over time, while the overall resistance pattern was still favorable. The overall mortality rate of BSIs decreased (5.2% vs. 2.6%).ConclusionsOver the 20-year study period, the spectrum of specific microorganisms among BSIs shifted, with opportunistic pathogens becoming predominant. Despite an increase in the proportion of antibiotic-resistant organisms, however, the mortality rate decreased.

Ulceroglandular tularemia in a toddler in Germany after a mosquito bite.

IntroductionAlthough tularemia is a long-known disease, its significance had diminished over the last decades in Middle Europe. However, over the past years, there is new evidence suggesting that tularemia has re-emerged in Germany. In 2007, the highest number of human cases for almost 50xa0years has been notified. Beside typical vectors, new ways of transmission seem to gain significance. So far, mosquito bite-transmitted tularemia has only been known from Scandinavia but not from Middle Europe.Case reportWe report the first case of a 1-year-old toddler from Southwestern Germany with mosquito bite-associated ulceroglandular tularaemia. The new and interesting features of this case are the young age of the patient and the unusual transmission route. The available data suggesting changes in the epidemiology for tularemia in Germany are reviewed. This is an interesting case of infantile tularemia with a very unusual transmission route, highlighting ongoing changes in the epidemiology of tularemia in Germany.

Response to the letter: non-specific diagnosis of bacterial pneumonia in children

Dear Editor, We are very grateful to Prof. Korppi for his valuable and stimulating comments on our retrospective procalcitonin (PCT) study in hospitalized children with acute respiratory tract infection (ARI). We fully agree with him that antibiotic use for ARI in children should be lessened as much as possible. We also agree that, in the probable future, bedside tests for PCT, CRP, and WBC might be available and allow differentiating between children who have to be treated with antibiotics and those who should not. It was the intention of our study to add to the existing body of evidence some preliminary data on PCT in children with ARI, clearly bearing in mind the limitations of a retrospective analysis. We also fully agree with Prof. Korppi that the 26 patients in our study with a PCT<0.1 ng/ml who were excluded from our analysis for a couple of different reasons would have been rather important for a most comprehensive conclusion. We do, however, not agree that these patients would have been the critical ones to draw any conclusion. In our study, we were interested in the first place to identify patients in whom antibiotics could be withheld with a great margin of safety and who therefore would be uncritical in a future intervention trial waiving antibiotic therapy. Furthermore, we believe that—even if many patients in our retrospective analysis were excluded—many health authorities and hospital leaders would be even quite satisfied when the antibiotic use could be reduced by one third (12/38). We agree, as mentioned above, that for a comprehensive conclusion it would have been desirable not to exclude any patient in order to meet most fairly the so-called field conditions. However, would this have been really reasonable? It is worthwhile to look in detail why these 26 patients were excluded. Some of these patients had a disease that was later on diagnosed as urinary tract infection. Others were pretreated with antibiotics. Others again had a severe underlying disease and would therefore not be the patients to include in a study on uncomplicated respiratory tract infection. Therefore, we agree that exclusion of these patients hampers a study like this, but in terms of preparing a prospective study protocol on uncomplicated ARI we probably would continue to exclude the patients whom we decided not to include in this retrospective analysis.

Successful Continuous Renal Replacement Therapy in a Neonate with Early-onset Group B Streptococcal Sepsis and Multi-organ Dysfunction Syndrome

BACKGROUNDnGroup B streptococcal early-onset sepsis (GBS EOS) in neonates has a mortality rate of approximately 5%, particularly in the presence of multi-organ dysfunction. Fluid management is crucial in these patients, and continuous venovenous haemofiltration (CVVH) should be considered a therapeutic option even in newborn babies.nnnCASE REPORTnAfter an uneventful pregnancy within hours after birth, a female term infant presented with dyspnoea, irritability and cyanosis. The systemic inflammatory response syndrome (SIRS) progressed to multi-organ dysfunction with acute respiratory distress syndrome (ARDS), impaired myocardial contractility, pulmonary hypertension and fluid overload. The maximum PRISM score was 51. The child required maximal respiratory and inotropic support with high volume intravenous fluid administration. However, only by using of CVVH from day 5 to 14, we successfully resolved progressive pulmonary and cardiovascular dysfunction. The child improved directly after initiation of fluid removal, was extubated on day 17 and discharged without obvious sequelae on day 57. All microbiology studies revealed GBS.nnnCONCLUSIONnPerinatal GBS-infections remain a major life-threatening event for newborn babies. CVVH should be considered an option for reversing fluid overload even in neonates with overwhelming SIRS. Alternatively, extracorporeal membrane oxygenation (ECMO) is discussed.

Epidemiologie von Staphylococcus aureus- Bakteriämien im Kindesalter – „säkulare Trends“

Staphylococcus aureus ist aufgrund der Haufigkeit, Virulenz und Antibiotikaresistenzentwicklung ein wichtiger Erreger von Bakteriamien im Kindesalter. In den letzten 10 Jahren sind S. aureus-Bakteriamie (SAB)-Inzidenzzahlen zwischen 8,4 und 105 pro 100 000 Kinder publiziert worden. Die hochsten Inzidenzen werden im Sauglingsalter beobachtet. Ein eindeutiger Trend uber Anstieg oder Abfall der Inzidenzzahlen ist nicht auszumachen. Die meisten SAB, vor allem im Sauglingsalter, sind im Krankenhaus erworben. Eine chronische Grunderkrankung oder zentrale Venenkatheter als Risikofaktoren weisen die meisten Kinder mit SAB auf und die Zahl dieser Patienten ist steigend. Die meisten Patienten mit SAB prasentieren sich mit einem klinischen Fokus. Die Letalitat der SAB ist in den letzten 10 Jahren gesunken. Bakteriamien mit Methicillin-resistenten Staphylokokken gewinnen auch im Kindesalter zunehmend an Bedeutung.