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Perinatal infection: detection and prevention
Semin Neonatol 2002; 7: 257–258 doi:10.1053/siny.2002.0120, available online at http://www.idealibrary.com on
EDITORIAL
Perinatal infection: detection and prevention A. G. S. Philip This issue of Seminars in Neonatology is devoted to the topic of Perinatal Infection. Emphasis has been placed on prevention. Although most of the important considerations under this heading are dealt with, it is not always possible to cover all aspects of a topic in a single issue. In particular, it should be noted that Perinatal HIV, including perinatal tuberculosis, was discussed in the August, 2000 issue, and Neonatal Bacterial Meningitis was covered in the April, 2001 issue. Readers should consult previous issues for information on these subjects. Regarding human immunodeficiency virus (HIV), it should be noted that progress continues to be made in devising strategies for reducing vertical transmission, by use of shorter courses of antiretrovirals (such as zidovudine, lamivudine, and nevirapine) [1,2] Lobbying efforts have also resulted in decreased costs [1]. Regarding neonatal meningitis, it is worth mentioning that both the incidence and the mortality and morbidity may be falling [3]. Whether or not this is the result of increased use of antibiotics by obstetricians is uncertain. It also remains to be seen whether this improvement will be sustained. Congenital toxoplasmosis remains an important consideration in some countries, but prevention strategies have not changed recently. In some populations, congenital syphilis remains prevalent [4]. In addition, the possibility of developing other vaccines for maternal use [5], or improving vaccines for neonatal use, are topics for the future. Also becoming a reality are methods for rapidly detecting bacterial and viral infection, such as the polymerase chain reaction [6]. A detailed discussion of the use of intravenous immunoglobulin (IVIG) was originally planned, but there is little recent evidence to change the opinions expressed in two recent Cochrane Reviews by Ohlsson and Lacy [7,8]. The conclusion of the first review is that ‘There is insufficient evidence to support the routine administration of 1084–2756/02/$-see front matter
IVIG preparations, investigated to date, to prevent mortality in infants with suspected or subsequently proved neonatal infection.’ The conclusion of the second review is that, ‘. . . from a clinical perspective a 3–4% reduction in nosocomial infections without a reduction in mortality or other important clinical outcomes is of marginal importance. . . . There is no justification for further randomized controlled trials testing the efficacy of previously studied IVIG preparations to reduce nosocomial infections in preterm and/or low birth weight infants.’ The topics that are discussed in this issue cover a wide area of concerns to those who deal with neonatal/perinatal medicine. Some subjects (e.g. prevention of prematurity) have not completely fulfilled earlier promise, but nevertheless remain topical. Others (e.g. vaccines for group B streptococcus (GBS), colony-stimulating factors) hold hope for the future, while yet others (e.g. GBS chemoprophylaxis, prevention of nosocomial infection) have already proved themselves in recent years. The remaining topics shed light on recent advances in perinatal infectious disease. Only by staying abreast of the latest information are we likely to make further progress. All of the authors provide food for thought, which can allow us to practice evidence-based medicine, although (in some cases) evidence about certain strategies continues to be lacking. I am grateful to the authors for their thoughtful and thought-provoking contributions. References 1 Karim SA, Karim QA, Adhikari M, et al. Vertical HIV transmission in South Africa: translating research into policy and practice. Lancet 2002; 359: 992–993. 2 Beckerman KP. Mothers, orphans, and prevention of pediatric AIDS. Lancet 2002; 359: 1168–1169. 3 Dellagrammaticas HD, Christodoulou C, Megaloyanni E, et al. Treatment of gram-negative bacterial meningitis in © 2002 Elsevier Science Ltd. All rights reserved.
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term neonates with third generation cephalosporins plus amikacin. Biol Neonate 2000; 77: 139–146. 4 Michelow IC, Wendel GD Jr, Norgard MV, et al. Central nervous system infection in congenital syphilis. N Eng J Med 2002; 346: 1792–1798. 5 Munoz FM, Englund JA, Cheesman CC, et al. Maternal immunization with pneumococcal polysaccharide vaccine in the third trimester of gestation. Vaccine 2002; 20: 826–837.
A. G. S. Philip
6 Nissen MD, Sloots TP. Rapid diagnosis in pediatric infectious diseases: the past, the present and the future. Pediatr Infect Dis J 2002; 21: 605–612. 7 Ohlsson A, Lacy JB. Intravenous immunoglobulin for suspected or subsequently proven infection in neonates. Cochrane Database Syst Rev 2001; CD001239. 8 Ohlsson A, Lacy JB. Intravenous immunoglobulin for preventing infection in preterm and/or low-birth-weight infants. Cochrane Database Syst Rev 2001; CD000361.
EDITORIAL
Perinatal infection: detection and prevention A. G. S. Philip This issue of Seminars in Neonatology is devoted to the topic of Perinatal Infection. Emphasis has been placed on prevention. Although most of the important considerations under this heading are dealt with, it is not always possible to cover all aspects of a topic in a single issue. In particular, it should be noted that Perinatal HIV, including perinatal tuberculosis, was discussed in the August, 2000 issue, and Neonatal Bacterial Meningitis was covered in the April, 2001 issue. Readers should consult previous issues for information on these subjects. Regarding human immunodeficiency virus (HIV), it should be noted that progress continues to be made in devising strategies for reducing vertical transmission, by use of shorter courses of antiretrovirals (such as zidovudine, lamivudine, and nevirapine) [1,2] Lobbying efforts have also resulted in decreased costs [1]. Regarding neonatal meningitis, it is worth mentioning that both the incidence and the mortality and morbidity may be falling [3]. Whether or not this is the result of increased use of antibiotics by obstetricians is uncertain. It also remains to be seen whether this improvement will be sustained. Congenital toxoplasmosis remains an important consideration in some countries, but prevention strategies have not changed recently. In some populations, congenital syphilis remains prevalent [4]. In addition, the possibility of developing other vaccines for maternal use [5], or improving vaccines for neonatal use, are topics for the future. Also becoming a reality are methods for rapidly detecting bacterial and viral infection, such as the polymerase chain reaction [6]. A detailed discussion of the use of intravenous immunoglobulin (IVIG) was originally planned, but there is little recent evidence to change the opinions expressed in two recent Cochrane Reviews by Ohlsson and Lacy [7,8]. The conclusion of the first review is that ‘There is insufficient evidence to support the routine administration of 1084–2756/02/$-see front matter
IVIG preparations, investigated to date, to prevent mortality in infants with suspected or subsequently proved neonatal infection.’ The conclusion of the second review is that, ‘. . . from a clinical perspective a 3–4% reduction in nosocomial infections without a reduction in mortality or other important clinical outcomes is of marginal importance. . . . There is no justification for further randomized controlled trials testing the efficacy of previously studied IVIG preparations to reduce nosocomial infections in preterm and/or low birth weight infants.’ The topics that are discussed in this issue cover a wide area of concerns to those who deal with neonatal/perinatal medicine. Some subjects (e.g. prevention of prematurity) have not completely fulfilled earlier promise, but nevertheless remain topical. Others (e.g. vaccines for group B streptococcus (GBS), colony-stimulating factors) hold hope for the future, while yet others (e.g. GBS chemoprophylaxis, prevention of nosocomial infection) have already proved themselves in recent years. The remaining topics shed light on recent advances in perinatal infectious disease. Only by staying abreast of the latest information are we likely to make further progress. All of the authors provide food for thought, which can allow us to practice evidence-based medicine, although (in some cases) evidence about certain strategies continues to be lacking. I am grateful to the authors for their thoughtful and thought-provoking contributions. References 1 Karim SA, Karim QA, Adhikari M, et al. Vertical HIV transmission in South Africa: translating research into policy and practice. Lancet 2002; 359: 992–993. 2 Beckerman KP. Mothers, orphans, and prevention of pediatric AIDS. Lancet 2002; 359: 1168–1169. 3 Dellagrammaticas HD, Christodoulou C, Megaloyanni E, et al. Treatment of gram-negative bacterial meningitis in © 2002 Elsevier Science Ltd. All rights reserved.
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term neonates with third generation cephalosporins plus amikacin. Biol Neonate 2000; 77: 139–146. 4 Michelow IC, Wendel GD Jr, Norgard MV, et al. Central nervous system infection in congenital syphilis. N Eng J Med 2002; 346: 1792–1798. 5 Munoz FM, Englund JA, Cheesman CC, et al. Maternal immunization with pneumococcal polysaccharide vaccine in the third trimester of gestation. Vaccine 2002; 20: 826–837.
A. G. S. Philip
6 Nissen MD, Sloots TP. Rapid diagnosis in pediatric infectious diseases: the past, the present and the future. Pediatr Infect Dis J 2002; 21: 605–612. 7 Ohlsson A, Lacy JB. Intravenous immunoglobulin for suspected or subsequently proven infection in neonates. Cochrane Database Syst Rev 2001; CD001239. 8 Ohlsson A, Lacy JB. Intravenous immunoglobulin for preventing infection in preterm and/or low-birth-weight infants. Cochrane Database Syst Rev 2001; CD000361.