Comparative Effectiveness and Safety of Empiric Ampicillin plus Gentamicin or Empiric Piperacillin-Tazobactam in the Neonatal Intensive Care Unit

BACKGROUND: This study was designed to assess piperacillin tazobactam (PT) as an alternative to ampicillin and gentamicin (AG) in neonates with suspected systemic infection. METHODS: A retrospective, unmatched population of AG (2007-2009) and PT (2009-2012) exposed infants were evaluated for initial effectiveness, adverse events, and subsequent morbidities or mortality. Data included gestational age, birth weight, sex, Apgar score, length of hospital stay, glomerular filtration rate for days 1 and 2, duration on mechanical ventilation, duration on oxygen therapy, incidence of sepsis (blood or cerebrospinal fluid culture positive), incidence of ventilator associated pneumonia, and incidence of necrotizing enterocolitis. All positive blood cultures during the study period were reviewed. Data about specific microorganisms and sensitivity to antibiotics were RESULTS: No significant differences in demographics or initial Apgar scores were noted. There were no significant differences in systemic rash or diaper rash. PT was associated with higher glomerular filtration rate on day two. Four infants had early onset sepsis with ampicillin resistant E. coli. One of these, in the PT group, had intermediate sensitivity to gentamicin as well. CONCLUSION: Use of PT as the initial empiric antibiotic was not associated with increased adverse outcomes. The challenge of ampicillin resistant Escherichia coli should encourage others to consider this change

Total and Fractionated Bilirubin during the First Week in the Neonatal Intensive Care Unit

Background. Fractionated bilirubin requires more blood (0.6 ml) than total bilirubin alone (0.2 ml). Our focus during the first week in the Neonatal Intensive Care Unit (NICU) is on prevention of Bilirubin Induced Neurologic Dysfunction and kernicterus, which do not require fractionation. We wanted to determine the benefit of knowing fractionated bilirubin in the first week. Methods. In this retrospective study, data were obtained from the first week for 1202 NICU inborn admissions. Results. Direct bilirubin was more than 2.0 mg/dl in only six infants (0.6%). Five had multisystem injury from hypoxic ischemic events. One also had congenital cytomegalovirus and another had a postoperative liver hematoma. Weekly multichem profiles would have detected these abnormalities. No specific therapy was initiated for any of these infants. Conclusions. Converting to total bilirubin alone would not alter treatment, but could reduce iatrogenic blood loss by 2.4 ml per infant

A Retrospective Descriptive Study of Stat TPN Orders in the Neonatal Intensive Care Unit

BACKGROUND: Total parenteral nutrition (TPN) is used in the Neonatal Intensive Care Unit (NICU) to meet metabolic demand and provide growth. To prevent harm from critical laboratory abnormalities, stat TPNs can be ordered urgently to change the content of infusing TPN. Each stat order breaks the daily cycle and often leads to additional stat orders. Limited supplies of ingredients brought focus on our liberal stat TPN policy and how to reduce the number of stat TPNs safely. The purpose of this project was to evaluate biochemical abnormalities associated with stat TPNs and identify leverage points to reduce stat TPNs in NICU patients. METHODS: Data from 1/1/10 to 6/30/10 were abstracted from Meditech, NeoData, and patient charts for NICU stat TPN orders. Demographics, laboratory results (sodium, potassium, calcium, and glucose), and key variables were gathered and critical laboratory values were identified. RESULTS: A total of 112 patients had evaluable orders for 255 stat TPNs. Mean gestation was 31 weeks (SD = 5) and birth weight was 1.744 kg (SD = 0.993). Seven (3%) were never infused. Twenty (12.6%) of first stat TPNs were from patients taking nothing by mouth. Eighty-eight of first stat TPNs had no critical labs (55% of initial stat TPNs). Of follow-up stat orders, 43% (38/89) followed unnecessary initial stat TPNs. Of the 55 abnormalities that generated the initial stat TPNs, 44 (80%) corrected. CONCLUSIONS: Fifty-two percent of stat TPNs could not be justified. For situations that were justified, 20% of laboratory abnormalities from initial stat TPNs were not corrected. These data provide an opportunity to reduce unnecessary costs and save limited resources

Abdominal Ultrasound and Abdominal Radiograph to Diagnose Necrotizing Enterocolitis in Extremely Preterm Infants

Necrotizing enterocolitis (NEC) is an important contributor towardmortality in extremely premature infants and Very Low Birth Weight(VLBW) infants. The incidence of NEC was 9% in VLBW infants(birth weight 401 to 1,500 grams) in the Vermont Oxford Network(VON, 2006 to 2010, n = 188,703).1 The incidence of NEC was 7%in 1993, increased to 13% in 2008, and decreased to 9% in extremelypreterm infants (22 to 28 weeks gestation) in the Neonatal ResearchNetwork Centers (1993 to 2012).2 The incidence of surgically treatedNEC varies from 28 to 50% in all infants who develop NEC.3 SurgicalNEC occurred in 52% in the VON cohort.1 In this cohort, the odds ofsurgery decreased by 5% for each 100 gram increase in birth.The incidence of surgical NEC has not decreased in the pastdecade.4 The mortality from NEC is significantly higher in infantswho need surgery compared to those who did not (35% versus 21%).1The case fatality rate among patients with NEC is higher in thosesurgically treated (23 to 36%) compared to those medically treated (5to 24%).3 In addition to surgery, NEC mortality rates are influencedby gestational age, birth weight,1,2,5 assisted ventilation on the day ofdiagnosis of NEC, treatment with vasopressors at diagnosis of NEC,and black race.6,7Extremely preterm infants who survive NEC are at risk for severeneurodevelopmental disability and those with surgical NEC have asignificantly higher risk of such delays (38% surgical NEC versus 24%medical NEC).8 Diagnosis of necrotizing enterocolitis is challengingand it is usually suspected based on non-specific clinical signs. Bell’scriteria and Vermont-Oxford Network criteria help in the diagnosisof NEC.Bell’s criteria, commonly used for diagnosis, staging, and planningtreatment of NEC, were described in 1978 and modified in 1986.9,10Bell’s stage I signs are non-specific: temperature instability, lethargy,decreased perfusion, emesis or regurgitation of food, abdominal distension,recurrent apnea, and on occasion, increased support withmechanical ventilation. Abdominal distension and emesis are morecommon than bloody stools in very preterm infants compared to terminfants.7 Abdominal radiographic findings are an integral part of Bell’scriteria. Identification of Bell’s stage I NEC (early NEC) with abdominalradiograph is challenging, as the features on abdominal radiograph(normal gas pattern or mild ileus) are non-specific. With progressionof NEC to Bell Stage IIA, the symptoms (grossly bloody stools,prominent abdominal distension, absent bowel sounds) and featureson abdominal radiographs (one or more dilated loops and focal pneumatosis)are more specific.On the other hand, the Vermont Oxford Network criteria for NECconsist of at least one physical finding (bilious gastric aspirate oremesis, abdominal distension or occult/gross blood in the stool inthe absence of anal fissure) and at least one feature on abdominalradiograph (pneumatosis intestinalis, hepatobiliary gas, or pneumoperitoneum).1 These features correspond to Bell Stage IIA or StageIIB and are not features of early NEC. Thus relying solely on abdominalradiograph for diagnosis of early NEC, as is practiced currently,has significant drawbacks especially in extremely premature infants.7Ultrasound has been suggested to improve the percentage of infantsdiagnosed with early NEC.11 However, this imaging modality is notused routinely in the diagnosis or management of NEC.As the incidence of surgical NEC and mortality from NEC continuesto be high, the literature to demonstrate the shortcomings ofabdominal radiographs and promise of abdominal ultrasound in diagnosisof NEC is reviewed

The Global Health System: Lessons for a Stronger Institutional Framework

Governmen

Population Pharmacokinetics of Intravenous Acyclovir in Preterm and Term Infants

Acyclovir is used to treat herpes infections in preterm and term infants; however, the influence of maturation on drug disposition and dosing requirements is poorly characterized in this population