Vasiliki Drossou-Agakidou

Administration of recombinant human granulocyte-colony stimulating factor to septic neonates induces neutrophilia and enhances the neutrophil respiratory burst and β2 integrin expression Results of a randomized controlled trial

Abstract The objective of this study was to investigate the effect of treatment with recombinant human granulocyte-colony stimulating factor (rhG-CSF) on the neutrophil count and function of preterm neonates with documented sepsis. For this purpose 62 preterm neonates with proven sepsis and 19 healthy preterm ones were studied. Of the 62 patients, 27 septic neonates had an absolute neutrophil count (ANC) >5000/mm3 (group A) and were scheduled not to receive rhG-CSF and 35/62 had an ANC <5000/mm3 (n= 35) and were randomly assigned either to receive rhG-CSF (group B) or not to receive it (group C). rhG-CSF (10 μg/kg) was administered for 3 consecutive days (0, 1, 2). The ANC, plasma levels of G-CSF (ELISA), neutrophil respiratory burst activity (NRBA) and neutrophil expression of CD11a, CD11b and CD11c (flow cytometry) were measured in all septic neonates on days 0 (onset of sepsis), 1, 3 and 5 and in the healthy neonates once within the first 2 days of life. We found that on day 0, G-CSF levels of all groups of septic neonates were significantly higher than those of the healthy ones. The highest levels were observed in group A. NRBA was diminished only in groups B and C and the expression of CD11a and CD11c was reduced in all groups of septic neonates. Administration of rhG-CSF resulted in a rapid and significant increase in ANC, NRBA and CD11a, CD11b and CD11c expression that persisted throughout the follow up. Conclusion The administration of granulocyte colony stimulating factor to septic neonates significantly increases the absolute granulocyte count and enhances the neutrophil respiratory burst and β2 integrin expression.

Use of ciprofloxacin in neonatal sepsis: lack of adverse effects up to one year.

Aim. To investigate the adverse effects of ciprofloxacin administered to neonates with sepsis on the hematologic indices, the hepatic and renal function and the joints and growth at 1 year follow-up. Methods. In this observational prospective study, 2 groups of septic neonates were studied, 116 neonates who received ciprofloxacin and 100 neonates matched for gestational age and birth weight who did not receive ciprofloxacin. In all neonates the leukocyte and platelet counts as well as the serum concentrations of transaminases, bilirubin, albumin, urea and creatinine were measured before initiation of treatment and on the 10th and 15th to 20th days after treatment initiation. In 77 and 83 infants of the ciprofloxacin and control groups, respectively, the growth at the end of the first year of life was evaluated. Results. No significant differences between the two groups were found in the hematologic and biochemical indices as well as growth at the end of the first year of life. Also no clinical evidence of arthropathy was observed. Conclusions. Treatment of neonatal sepsis with ciprofloxacin resulted in no short term hematologic, renal or hepatic adverse effects and did not appear to be associated with clinical arthropathy or growth impairment at 1 year follow-up evaluation.

Flow cytometric measurement of HLA-DR expression on circulating monocytes in healthy and sick neonates using monocyte negative selection

The aim of this study was to investigate the effect of prematurity, neonatal sepsis, respiratory distress syndrome (RDS) and perinatal asphyxia on monocyte HLA‐DR expression of neonates using a flow cytometric method based on monocyte negative selection. The subjects were one hundred and thirty‐one neonates (59 healthy, 44 septicaemic, 20 with RDS and eight with perinatal asphyxia) and 20 healthy adults. Monocyte HLA‐DR expression was measured using one‐colour HLA‐DR labelling in a gate for monocytes obtained using the combination of CD3‐CD19–PE/CD15–FITC MoAbs. In addition, the common dual staining method using MoAbs against two CD14 epitopes (TUK4, MO2) was evaluated. With the one‐colour HLA‐DR labelling higher purity and recovery values of monocytes were achieved than with the dual labelling method. Healthy neonates had significantly lower percentages of HLA‐DR+ monocytes than adults (69 ± 13% versus 91·5 ± 2·5%) and comparable mean fluorescence intensity (MFI) (119 ± 25 versus 131 ± 26). Values did not differ significantly between healthy term and preterm neonates. Preterm neonates with RDS had a significantly lower percentage of HLA‐DR+ monocytes than the healthy preterm neonates. In neonates with asphyxia both parameters were comparable to those of the healthy ones. Septicaemic neonates presented significantly lower values of both parameters than the healthy, RDS and asphyxiated neonates. Monocyte negative selection provides a reliable estimation of HLA‐DR expression on monocytes. Expression of monocyte HLA‐DR is lower in healthy neonates in comparison with adults and is further decreased in neonates with sepsis and RDS, but it is not influenced by prematurity and perinatal asphyxia.

Short-term and long-term mortality following pediatric intensive care.

Background:  The aim of the present study was to examine short‐term and long‐term mortality following discharge from the pediatric intensive care unit (PICU).

Use of Tigecycline in Pediatric Patients With Infections Predominantly Due to Extensively Drug-Resistant Gram-Negative Bacteria

Background. Emergence of extensively drug-resistant (XDR) bacteria has forced clinicians to use off-label antimicrobial agents such as tigecycline. We present our experience on salvage use of tigecycline for the treatment of infections caused by XDR Gram-negative bacteria in critically ill children and review published cases. Methods. We conducted a retrospective chart review in pediatric departments of a tertiary level hospital from January 2009 to May 2014. Patients were identified using pharmacy database. For the literature review, relevant articles were identified from PubMed. Results. In our case series, 13 children (7 males) with a median age of 8 years (range, 2.5 months-14 years) received tigecycline for ≥2 days as treatment for healthcare-associated infections including 5 bacteremias, 6 lower respiratory tract infections, and 3 other infections. Isolated pathogens were XDR Gram-negative bacteria except 1. A loading dose (range, 1.8-6.5 mg/kg) was given in all except 2 cases. Maintenance dose was given at 1-3.2 mg/kg q12 h. Other antimicrobials including colistin and aminoglycosides (85% and 62%, respectively) were coadministered to all patients. No serious adverse events were detected in these very ill children. Twenty cases of children treated with tigecycline were previously published, mostly for multidrug-resistant/XDR bacteria. An episode of acute pancreatitis and neutrophil engraftment delay in 2 cases were reported during tigecycline treatment. Analyzing reported and all our cases together, mortality in bloodstream infections was 86%, whereas in nonbacteremic cases it was 24% (P = .009). Conclusions. Tigecycline, given at the range of administered doses as salvage therapy and in combination with other antimicrobial agents, seemed to be well tolerated in a series of mainly critically ill pediatric patients and demonstrated relatively good clinical response in nonbacteremic patients.

Hydrothorax as a Sole Manifestation of Congenital Parvovirus B19 Infection

We present a case of congenital parvovirus B19 infection in a term neonate manifested with isolated massive hydrothorax and mild anemia. Parvovirus B19 DNA was detected in maternal and neonatal blood as well as in pleural fluid despite lack of suggestive serology.

991 Serum and Urine Cystatin C and Neutrophil Gelatinase-Associated Lipocalin |[lpar]|NGAL|[rpar]| in Asphyxiated Term Neonates: Preliminary Results

Background: Cystatin C (CysC) and neutrophil gelatinase-associated lipocalin (NGAL) are novel biomarkers of acute kidney injury (AKI). Objective: To evaluate CysC and NGAL in the serum and urine of term neonates with AKI secondary to acute asphyxia. Patients-methods: Prospective study in term neonates with severe acute asphyxia and AKI (n=8, serum creatinine ≥1.5 mg/dL or rising values >0.3 mg/dL from baseline) and healthy term ones (n=10). Blood and urine samples were obtained on day 1 and 3 of life (DOL) for CysC and NGAL measurement (ELISA). Results: Serum CysC was increased in neonates with asphyxia-AKI vs. healthy ones without the differences being significant (DOL 1; 2.04±1.02 mg/L vs. 1.85±0.35 mg/L, p=0.609, DOL 3; 2.04±1.13 vs.1.65±0.35 mg/L, p=0.435). Similarly, serum NGAL was higher -although not significantlyon DOL 1 (155.3±140 ng/mL vs. 55.2±33 ng/mL, p=0.087) and DOL 3 (144.2±151 ng/mL vs. 23.9±9.6 ng/mL, p=0.109) in neonates with AKI. In the latter group, however, significantly increased urine values of CysC (DOL 1; 275±0.127 ng/mL vs. 42±127 ng. L, p=0.003, DOL 3; 279±102 vs. 51.6±38 ng/ mL, p=0.001) and NGAL (DOL 1; 16.8±4.1 ng/ mL vs. 10.8±5.3 ng/mL, p=0.03, DOL 3; 16.6±6.2 vs.12.3±6.7 ng/mL, p=0.226) were observed. Serum creatinine was significantly positively correlated with serum and urine CysC and NGAL. Unlike NGAL, a significant positive correlation was found between serum and urine CysC. Conclusions: In asphyxiated term neonates with AKI, CysC and NGAL significantly increase only in urine. Thus, their measurement in urine may be better than in serum for AKI evaluation in term neonates.

261 The Epidemiology of Diabetes in Pregnancy and Maternal Characteristics in Northern Greece

Aims: To determine the prevalence of diabetes in pregnancy and evaluate maternal characteristics according to the type of diabetes. Methods: We prospectively studied the maternal characteristics of all neonates who were born in our perinatal center and were treated in our department during the period 1996-2007. Infants of diabetic mothers were classified in three groups: Group A: mothers with preexisting diabetes, Group B: mothers with gestational diabetes, managed with insulin, Group C: mothers with gestational diabetes, managed with diet. Non diabetic mothers served as control. Results: Overall, 20.643 live neonates from 19.791 pregnancies were studied. Of them, 852 were complicated by diabetes. The incidence of DP was 1.86% from 1996 to 2000 and 5.57% from 2001 to 2007. Maternal-neonatal characteristics are shown in the table (*p< 0.001). Conclusions: The incidence of DP increased during the last 6 years. The prevalence of IVF is significantly elevated only in gestational diabetes treated with insulin. Also, in term neonates, birth weight was significantly higher only in women with preexisiting diabetes. These results, however, need to be confirmed in other studies.

1408 Epidemiology of Early-Onset Sepsis in a Nicu During a 12-Year Period (1996-2007)

Aim: To determine the incidence and the causative pathogens of early-onset sepsis (EOS ≤ 3rd day of life). Patients-Methods: We prospectively studied the perinatal and neonatal characteristics of all neonates who were born in our perinatal center and were treated in our department, as well as all neonates admitted in our tertiary NICU from the area of Macedonia and Thessaly, during the period 1996-2007. Neonates with positive blood culture were further studied according to the time of the 1st sepsis episode and causative pathogen isolated. Results: During the study period, 9113 neonates were admitted to the NICU. Of them, EOS had 229 (2.5%) neonates. In the 73.4% of them, gram positive bacteria were isolated. Most common causative pathogens were: Coagulase negative Staphylococci (48.5%), Escherichia coli (11.8%), Staphylococcus aureus (7.9%), Klebsiella (5.2%), GBS (4.8%), Streptococci (other, 4.8%), Enterococcus (3.9%), Pseudomonas (3.1%), Enterobacteria (2.2%), Acinetobacter (2.2%), Streptococcus viridans (1.3%), Candida albicans (1.3%), Listeria (0.9%), Serratia(0.4%), Hemophilus (0.4%), Streptococcus pneumonia (0.4%) and Brucella melitensis (0.4%). Of the 20.643 neonates born alive at our center, 101 (0.49%) had EOS. Also, EOS developed in 3.1% of the inborn neonates with BW < 1500g, and 2.7% with GA< 33 wks, of whom 45.9% and 51.4%, respectively, had EOS from gram negative and positive bacteria. Conclusion: The most common bacteria for EOS in our NICU were staphylococci sp., whereas GBS and Listeria are not important in the epidemiology of EOS. Gram negative bacteria are involved mostly in inborn babies with GA< 33 wks.

78 Neutrophil Apoptosis in Neonates with Intrauterine Growth Retardation Born to Normotensive Mothers

Background: Neutropenia is a common manifestation in neonates with intrauterine growth retardation (IUGR) related to preeclampsia and has been associated with decreased neutrophil production. In addition, the increased serum levels of soluble Fas Ligand (sFasL) found in neonates born to mothers with preeclampsia have been associated with increased apoptosis. Neutropenia is uncommon in neonates with isolated IUGR. AIM. To assess neutrophil apoptosis in neonates with IUGR born to normotensive mothers.Material and methods: Neutrophil apoptosis was studied in 19 neonates with IUGR born to mothers without hypertension and 19 gestational age matched, appropriate for gestational age (AGA) neonates during the first 12 hours after birth. Neutrophil apoptosis was evaluated by flow cytometric assessment of neutrophils stained with fluorescein isothiocynate (FICT)-annexin-V, propidium iodide (PI) or expressing the Fas molecule.Results: No significant difference in the percentage of neutrophills stained with FICT-annexin-V (mean7,1%, SD 3,9% vs mean 7,8% SD 2,5%, respectively) or with PI (mean 7,6%, SD 4,3% and mean 7,8%, SD 3,4%, respectively) was found between the IUGR and the AGA neonates. Also the percentage of neutrophills expressing the Fas did not differ significantly between the IUGR (mean 30,2%, SD 11,3%) and AGA neonates (mean 24,8%, SD 9,3%).Conclusion: Neutrophil apoptosis in IUGR neonates of normotensive mothers is not increased compared to AGA neonates. We speculate that neutropenia in IUGR is rather attributed to preeclampsia than intrauterine starvation.