Timothy R Cooper

Rapid Detection of Microorganisms in Blood Cultures of Newborn Infants Utilizing an Automated Blood Culture System

Background. Neonatal sepsis is a low incidence, high-risk disease with many sepsis work-ups performed to detect a single case. Seventy-two hours of antibiotic therapy have been traditionally recommended pending negative culture results. Improved culture media and new technology integrated into blood culture systems could shorten incubation time required to detect positive culture results. This would then change the length of antibiotic therapy in the management of the newborn infant with suspected sepsis. In addition, previous data supporting the 72-hour recommendation were retrospectively acquired, utilized nonautomated systems, and reported in an era with a different population of microorganisms cultured in special care nurseries. Objective. Evaluate the time of incubation to detect positive blood cultures from newborn infants with suspected sepsis using a computer-assisted, automated blood culture system, ESP (Trek Diagnostic Systems, Inc, Westlake, OH). Design. Prospective, observational study. Patients and Setting. All positive blood culture results that were obtained from term and preterm newborn infants born from November 1993 through June 1997 at a publicly funded hospital with over 6000 live births per year. Methods. As positive blood culture results were identified, data were prospectively obtained from the patients medical record. The computer algorithm in the automated blood culture system determined the time to positivity. Time to positivity was determined for blood cultures obtained before the initiation antimicrobial therapy and compared with those cultures obtained after beginning therapy. Time to positivity was also evaluated for clinically important Gram-positive and Gram-negative bacteria and yeast. Results. Four hundred fifty-five positive blood culture results were obtained from 222 patients. Gram-positive organisms accounted for 80% (366/455) of the positive culture results, Gram-negative organisms accounted for 11% (48/455), and yeast for 9% (41/455). Virtually all cultures growing clinically significant Gram-positive and Gram-negative organisms were positive by 24 to 36 hours of incubation. Cultures growing Staphylococcus epidermidis were virtually all positive after 36 to 48 hours of incubation. Of cultures growing yeast, 88% (36/41) were positive by 48 hours of incubation. There was no difference in time to positivity in pretherapy or posttherpay obtained positive blood cultures. Prenatally administered antibiotics did not affect time to positivity in positive cultures drawn on the first day of life. In a selected group of microorganisms that are the frequent cause of bacteremia in term infants, 97% and 99% of cultures were positive by 24 to 36 hours of incubation when only pretherapy cultures are evaluated. Conclusions. The ESP blood culture system identified 77%, 89% and 94% of all microorganisms at 24, 36, and 48 hours of incubation in aerobic cultures obtained from both term and preterm infants. Introduction of antimicrobial therapy did not affect time to positivity. Reducing duration of antibiotic therapy to 24 to 36 hours should be considered in term, asymptomatic newborn infants undergoing evaluation for suspected sepsis for maternal indications. Confirmation of similar rapidity of detection using other blood culture systems should be undertaken.

Long-term Outcomes of Group B Streptococcal Meningitis

OBJECTIVE: Group B Streptococcus (GBS) is the leading cause of meningitis in young infants. We evaluated long-term outcomes among GBS meningitis survivors. We hypothesized that despite reduced mortality, GBS meningitis would remain a significant cause of morbidity among GBS survivors. METHODS: Ninety term and near-term infants diagnosed with GBS meningitis from 1998 through 2006 were identified from 2 children’s hospitals. Five died acutely, and 5 died at 6 months to 3 years of age. Forty-three survivors (54%; mean age 6.8, range 3–12 years) were consented for evaluation and underwent physical and neurologic examinations, hearing and vision screening, and standardized developmental assessments. Associations among presenting features, laboratory parameters, neurologic status at hospital discharge, and later developmental outcomes were explored by using descriptive statistics and logistic regression. RESULTS: Twenty-four of 43 (56%) children evaluated demonstrated age-appropriate development, 11 (25%) had mild-to-moderate impairment, and 8 (19%) had severe impairment. Admission features associated with death after hospital discharge or severe impairment included lethargy (P = .003), respiratory distress (P = .022), coma or semicoma (P = .022), seizures (P = .015), bulging fontanel (P = .034), leukopenia (P = .026), acidosis (P = .024), cerebrospinal fluid protein >300 mg/dL (P = .006), cerebrospinal fluid glucose <20 mg/dL (P = .026), and need for ventilator (P = .002) or pressor support (P < .001). Features at discharge associated with late death or severe impairment included failed hearing screen (P = .004), abnormal neurologic examination (P < .001), and abnormal end of therapy brain imaging (P = .038). CONCLUSIONS: Survivors of GBS meningitis continue to have substantial long-term morbidity, highlighting the need for ongoing developmental follow-up and prevention strategies such as maternal immunization.

Managing Disagreements in the Management of Short Bowel and Hypoplastic Left Heart Syndrome

Background and Objectives. When innovative, not yet fully proven therapies are introduced, physicians may have neither experience nor sufficient data in the medical literature to assist in their decision to discuss them with and/or recommend them to patients. Little is known about how physicians deal with this uncertainty. Moreover, when multiple physicians caring for a single patient have reached different conclusions regarding this new therapy, the potential for disagreement exists that could give rise to ethical issues as well as cause confusion to the patient. To explore these topics, we investigated the attitudes of specialists to therapies for two life-threatening diseases: hypoplastic left heart syndrome (HLHS) and short bowel syndrome. Methods. A forced choice questionnaire was distributed to the heads of neonatology, pediatric cardiology, and pediatric gastroenterology training programs asking about their outcome impressions and treatment recommendations and about the local availability of treatments. In addition, responses from specialists from the same institution were linked in a confidential manner to evaluate the frequency of disagreement within the same institution. Responses were analyzed using χ2 and Wilcoxon matched pair analysis as appropriate. Results. The overall rate of response was 79%. In institutions that had both neonatology and pediatric gastroenterology training programs, there was a 59% response rate compared with a 73% response rate from institutions that had both neonatology and cardiology programs. Significant differences were noted among specialists as to who would be involved in discussions of therapeutic options with patients in both HLHS and short bowel syndrome. Differences also were noted in the willingness of specialists to discuss and recommend therapies, in the perceived survival and quality of life by various specialists after transplant and palliative surgery, and in the local availability of various options. The neonatologists and gastroenterologists at the same institution disagreed on responses in 34% of the questions with only 1 of the 25 pairs in full agreement. In contrast, the neonatologists and pediatric cardiologists at the same institution disagreed in only 14% of the questions with 7 of the 28 pairs in full agreement. Conclusions. Substantial disagreement among specialists about new interventions was found. There seem to be fewer differences among specialists when dealing with the more mature therapy, HLHS. Two major ethical issues arise. First, there seems to be no accepted professional standard to which individuals can appeal when determining whether to discuss or recommend new, not-yet-fully-proven technologies. Second, there is the potential for much patient confusion when counseling physicians recommend different options. Colleagues as individuals and specialists as groups should talk to each other before individual discussions with families to ensure that there is a clear understanding of differing beliefs.

Effect of Necrotizing Enterocolitis (NEC) on Length of Hospital Stay and Estimated Hospital Charges

Effect of Necrotizing Enterocolitis (NEC) on Length of Hospital Stay and Estimated Hospital Charges

Paradoxical Aspects of Inter-Professional Disagreements in the Management of Short Gut |[dagger]| 153

In the management of short gut, alternatives to long term total parenteral nutrition (TPN) exist, ranging from enteral feeding only to interventional, surgical management such as gut transplant or gut lengthening procedures. To understand attitudes and practice concerning short gut management, a survey was sent in the spring of 1997 to the directors of 102 Neonatology (Neo) and 47 Gastroenterology (GI) fellowship programs with 70% and 85% response respectively. Chi square with Yates correction and Wilcoxon matched paired analysis are used as appropriate.

A Single Equation Describes Actuarial Survival for All Gestational Age (GA) Infants Admitted to Neonatal Intensive Care, Independent of Gestation • 1226

A Single Equation Describes Actuarial Survival for All Gestational Age (GA) Infants Admitted to Neonatal Intensive Care, Independent of Gestation • 1226

ACTUARIAL SURVIVAL TO DISCHARGE IN THE PREMATURE INFANT LESS THAN 30 WEEKS GESTATION. ▴ 1549

Survival to discharge has been well studied in the premature infant. However, the traditional method, life-table analysis, is based uponsurvival from admission or birth. This data does not provide information about future life expectancy, which changes as the child matures. In contrast, actuarial-survival analysis describes future life expectancy from a given postnatal age and has not been described in an inborn population of premature infants less than 30 weeks gestation.

CURRENT EPIDEMIOLOGY AND LABORATORY EVALUATION OF CONGENITAL SYPHILIS IN AN URBAN POPULATION |[dagger]| 1658

Among urban, parturient women in the US, the rate of positive serologic tests for syphilis is 2%-6%. The purpose of this study was to review the epidemiology of syphilis in our perinatal population and to determine if results of the routine laboratory evaluation affected infant treatment. Our publicly funded hospital delivered 12,922 infants in 1992 and 1993: 82% Hispanic, 13% black. Universal screening at delivery identified a positive MHA-TP in 345 women (2.2%). Medical records were reviewed for maternal history, demographic data, and infants hospital course. Blacks had higher odds of positive serology vs Hispanics (odds ratio=11.3, 95% CI 8.8-14.3). Seropositive mothers with no treatment, undocumented treatment, partial treatment, or evidence of reinfection were considered untreated. Evaluations for congenital syphilis included a physical examination; complete blood count(CBC); platelet count; ALT, AST, and direct bilirubin; urinalysis; RPR and MHA-TP; cerebrospinal fluid (CSF) cell count, protein, and VDRL; and long bone radiographs. Table