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A10 Outcome of term breech births: a 15-year experience
Selected abstracts / Early Human Development 88S2 (2012) S101–S115
possibility of progression to invasive dissemination of the colonies of C. glabrata isolated. In our view, the exposure to fluconazole could have ensured a fungistatic – though not fungicidal – effect even with species with dose-dependent susceptibility to fluconazole. When a positivity for C. glabrata was later detected from a central highrisk site (CVC), thus meaning that the fungus was no more confined to peripheral sites at low risk (gastrointestinal and respiratory system), the risk of progression to dissemination of the fungus in the bloodstream prompted us to institute a treatment with a fungicidal agent such as amphotericin B. This strategy proved effective and safe, and resulted in negativisation of cultures and to ultimately discharge the baby at 39 weeks of postmenstrual age with no further risks. Conclusions: Antifungal prophylaxis with fluconazole, though effective in most cases, requires a careful monitoring of the microbiological status of the infant to rapidly detect both the presence and the localisation of fungal species of Candida with low or no sensitivity to fluconazole. This enables caregivers to perform early, appropriate treatment with systemic antifungals other than fluconazole when needed. Reference(s) [1] Manzoni P, Arisio R, Mostert M, Leonessa ML, Farina D, Latino MA, Gomirato G. Prophylactic fluconazole is effective in preventing fungal colonization and fungal systemic infections in preterm neonates: a single-center, 6-year retrospective cohort study. Pediatrics 2006 Jan;117(1):e22–32. Epub 2005 Dec 1 [2] Castagnola E, Machetti M, Bucci B, Viscoli C. Antifungal prophylaxis with azole derivatives. Clin Microbiol Infect 2004; 10 Suppl 1:86–95. A10 Outcome of term breech births: a 15-year experience N. Sindiˇcic´ Dessardo1 , P. Branimir1 , S. Dessardo1 , O. Petrovic´ 1 . 1 Department of Gynecology and Obstetrics, Institute of Neonatology, University Hospital of Rijeka, Croatia Objective: To review the short and long term outcomes among singelton infants with breech presentation at term delivered over 15-year period. Design: Retrospective, cohort study. Setting: University Hospital Rijeka, Croatia, Department of Gyn & Obst., Neonatology institute. Population: 1567 term breech infants alive at the onset of labour and born between January 1993 and December 2008. Methods: Data abstracted from birth registers, neonatal discharge summaries and child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (vaginal and prelabour caesarean section or cesarean section in labour). Fisher‘s exact test was used to compare the catergorical variables. Main outcome measures: Short term outcomes: perinatal mortality, Apgar score, admission to NICU, birth trauma and neonatal seizures. Long term outcomes: death during infancy, cerebral palsy, long term morbidity (development of special needs and special education needs). Results: Of 1567 singleton term infants in breech presentation at onset of labour, 1056 (67.4%) were delivered vaginally and 511 (32.6%) were born by caesarean section. In the second group 46 (9%) were born born by caesarean section in labour and 465 (91%) were born by prelabour caesarean section. There were 2 (1.8%) non-malformed perinatal deaths among infants born by vaginal delivery compared with one (1.9%) in the cesarean section group. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, p < 0.0001) and require admission to the NICU (1.6% vs 4%, p = 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal delivery vs 3.8% in the caesarean group, p = 0.26); no difference in rates of cerebral palsy; and non of the three infant deaths were related to the mode of delivery. Conclusions: Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term and morbidity, although the mortality was same in both groups. The long term outcome was not influenced by the mode of delivery.
S105
A11 Polymicrobial sepsis in hospitalised infants P.B. Smith1 , D. Hsu1 , M. Cohen-Wolkowiez1 , H.C. Reese2 , L.C. Downey1 , D.K. Benjamin Jr.1 . 1 Department of Pediatrics, Duke University Medical Center, Durham, NC, USA; 2 Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA Introduction: A polymicrobial blood stream infection (BSI) is the simultaneous invasion of the bloodstream by two or more pathogenic microorganisms. Previous studies of polymicrobial BSIs in adults, children, and infants are few and are often limited to single-centre reports. Thus, the objective of this study was to describe the causative organisms of these infections, predictors of polymicrobial sepsis, and clinical outcomes in a large and diverse population of infants admitted to the neonatal intensive care unit (NICU). Methods: We examined blood culture results of all infants admitted to 292 NICUs managed by the Pediatrix Medical Group in the United States between 1997 and 2009. We defined polymicrobial sepsis as a single blood culture with more than one pathogenic organism. We excluded BSI episodes for organisms considered contaminants including possible CoNS infections. We used univariable and multivariable regression to determine the association of gestational age, birth weight, race, sex, five-minute Apgar score, maternal age, exposure to antenatal antibiotics, exposure to antenatal steroids, inborn/outborn status, premature rupture of membranes, and mechanical ventilator use of day of life 1 with the presence of polymicrobial sepsis. Results: Of 523,267 patients admitted to Pediatrix NICUs during this period, 376,405 (72%) were evaluated with a blood culture, 17,959 (4.8%) had a positive monomicrobial blood culture, and 292 (1.6%) subjects had 296 polymicrobial blood cultures in the first 120 days of life. The mean birth weight for the infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis was 2492 g (5th, 95th percentiles: 1006, 3948), 1573 g (559, 3632), and 1199 g (515, 3112), respectively. The mean gestational age at birth for infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis was 35 weeks (28, 40), 30 weeks (24, 40), and 28 weeks (23, 39), respectively. Gram-positive organisms were most frequently involved in polymicrobial infections (230/296, 78%), followed by Gram-negative organisms (172/296, 58%) and Candida (42/296, 14%). Mortality rates for infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis were 1.5% (5099/332,884), 11% (1775/15,623), and 13% (31/247), respectively. Polymicrobial sepsis that involved Candida was associated with the highest mortality (gram-negative/Candida, 3/10 [30%], and gram-positive/Candida, 6/23 [26%]). Mortality involving gram-negative/ gram-negative infections was 7/43 (16%), gram-negative/gram-positive was 9/88 (10%), and gram-positive/gram-positive was 6/83 (7%). On multivariable regression, increasing birth weight (OR 0.46 [95% CI 0.28–0.76], p < 0.01) and increasing gestational age (OR 0.89 [0.82–0.97], p < 0.01) were associated with a decreased risk of polymicrobial sepsis, and need for mechanical ventilation on day of life 1 (OR 3.56 [2.35–5.39], p < 0.01) was associated with a higher risk of polymicrobial sepsis. Discussion: This study presents predictors of infection and outcomes for the largest cohort of infants with polymicrobial BSIs to date. Low gestational age, low birth weight, and need for mechanical ventilation on day of life 1 were associated with development of polymicrobial sepsis. Mortality associated with polymicrobial sepsis was lower in this cohort of infants (13%) than previously reported. A12 The Piedmontese Regional Referral Center for the management of retinopathy of prematurity: a 6-year report M. Brandozzi1 , E. Giacosa1 , G. Garbo2 , G. Anselmetti1 . 1 Ophthalmology Department Regional Referral Center for ROP, Torino, Italy; 2 Neonatal Intensive Care Unit. Maria Vittoria Hospital, Torino, Italy Aim: To study ROP features in infants of any gestational age affected by ROP evaluated in the last 6 years in our Regional Referral Center for retinopaty of prematurity. Material and Methods: A retrospective review was performed on all the patients (175) with diagnosis of ROP who were referred to our Regional Referral Center from 2006 to 2011 and who received further diagnostic evaluation and – in selected cases – surgical or laser treatment. Results: A total of 175 patients affected by ROP were evaluated in our Center. Their mean gestational age was 25.7+2SD weeks (range
possibility of progression to invasive dissemination of the colonies of C. glabrata isolated. In our view, the exposure to fluconazole could have ensured a fungistatic – though not fungicidal – effect even with species with dose-dependent susceptibility to fluconazole. When a positivity for C. glabrata was later detected from a central highrisk site (CVC), thus meaning that the fungus was no more confined to peripheral sites at low risk (gastrointestinal and respiratory system), the risk of progression to dissemination of the fungus in the bloodstream prompted us to institute a treatment with a fungicidal agent such as amphotericin B. This strategy proved effective and safe, and resulted in negativisation of cultures and to ultimately discharge the baby at 39 weeks of postmenstrual age with no further risks. Conclusions: Antifungal prophylaxis with fluconazole, though effective in most cases, requires a careful monitoring of the microbiological status of the infant to rapidly detect both the presence and the localisation of fungal species of Candida with low or no sensitivity to fluconazole. This enables caregivers to perform early, appropriate treatment with systemic antifungals other than fluconazole when needed. Reference(s) [1] Manzoni P, Arisio R, Mostert M, Leonessa ML, Farina D, Latino MA, Gomirato G. Prophylactic fluconazole is effective in preventing fungal colonization and fungal systemic infections in preterm neonates: a single-center, 6-year retrospective cohort study. Pediatrics 2006 Jan;117(1):e22–32. Epub 2005 Dec 1 [2] Castagnola E, Machetti M, Bucci B, Viscoli C. Antifungal prophylaxis with azole derivatives. Clin Microbiol Infect 2004; 10 Suppl 1:86–95. A10 Outcome of term breech births: a 15-year experience N. Sindiˇcic´ Dessardo1 , P. Branimir1 , S. Dessardo1 , O. Petrovic´ 1 . 1 Department of Gynecology and Obstetrics, Institute of Neonatology, University Hospital of Rijeka, Croatia Objective: To review the short and long term outcomes among singelton infants with breech presentation at term delivered over 15-year period. Design: Retrospective, cohort study. Setting: University Hospital Rijeka, Croatia, Department of Gyn & Obst., Neonatology institute. Population: 1567 term breech infants alive at the onset of labour and born between January 1993 and December 2008. Methods: Data abstracted from birth registers, neonatal discharge summaries and child health database system were used to compare the short and long term outcomes of singleton term breech infants born by two different modes of delivery (vaginal and prelabour caesarean section or cesarean section in labour). Fisher‘s exact test was used to compare the catergorical variables. Main outcome measures: Short term outcomes: perinatal mortality, Apgar score, admission to NICU, birth trauma and neonatal seizures. Long term outcomes: death during infancy, cerebral palsy, long term morbidity (development of special needs and special education needs). Results: Of 1567 singleton term infants in breech presentation at onset of labour, 1056 (67.4%) were delivered vaginally and 511 (32.6%) were born by caesarean section. In the second group 46 (9%) were born born by caesarean section in labour and 465 (91%) were born by prelabour caesarean section. There were 2 (1.8%) non-malformed perinatal deaths among infants born by vaginal delivery compared with one (1.9%) in the cesarean section group. Compared with infants born by prelabour caesarean section, those delivered vaginally or by caesarean section in labour were significantly more likely to have low 5-minute Apgar scores (0.9% vs 5.9%, p < 0.0001) and require admission to the NICU (1.6% vs 4%, p = 0.0119). However, there was no significant difference in the long term morbidity between the two groups (5.3% in the vaginal delivery vs 3.8% in the caesarean group, p = 0.26); no difference in rates of cerebral palsy; and non of the three infant deaths were related to the mode of delivery. Conclusions: Vaginal breech delivery or caesarean section in labour was associated with a small but unequivocal increase in the short term and morbidity, although the mortality was same in both groups. The long term outcome was not influenced by the mode of delivery.
S105
A11 Polymicrobial sepsis in hospitalised infants P.B. Smith1 , D. Hsu1 , M. Cohen-Wolkowiez1 , H.C. Reese2 , L.C. Downey1 , D.K. Benjamin Jr.1 . 1 Department of Pediatrics, Duke University Medical Center, Durham, NC, USA; 2 Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA Introduction: A polymicrobial blood stream infection (BSI) is the simultaneous invasion of the bloodstream by two or more pathogenic microorganisms. Previous studies of polymicrobial BSIs in adults, children, and infants are few and are often limited to single-centre reports. Thus, the objective of this study was to describe the causative organisms of these infections, predictors of polymicrobial sepsis, and clinical outcomes in a large and diverse population of infants admitted to the neonatal intensive care unit (NICU). Methods: We examined blood culture results of all infants admitted to 292 NICUs managed by the Pediatrix Medical Group in the United States between 1997 and 2009. We defined polymicrobial sepsis as a single blood culture with more than one pathogenic organism. We excluded BSI episodes for organisms considered contaminants including possible CoNS infections. We used univariable and multivariable regression to determine the association of gestational age, birth weight, race, sex, five-minute Apgar score, maternal age, exposure to antenatal antibiotics, exposure to antenatal steroids, inborn/outborn status, premature rupture of membranes, and mechanical ventilator use of day of life 1 with the presence of polymicrobial sepsis. Results: Of 523,267 patients admitted to Pediatrix NICUs during this period, 376,405 (72%) were evaluated with a blood culture, 17,959 (4.8%) had a positive monomicrobial blood culture, and 292 (1.6%) subjects had 296 polymicrobial blood cultures in the first 120 days of life. The mean birth weight for the infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis was 2492 g (5th, 95th percentiles: 1006, 3948), 1573 g (559, 3632), and 1199 g (515, 3112), respectively. The mean gestational age at birth for infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis was 35 weeks (28, 40), 30 weeks (24, 40), and 28 weeks (23, 39), respectively. Gram-positive organisms were most frequently involved in polymicrobial infections (230/296, 78%), followed by Gram-negative organisms (172/296, 58%) and Candida (42/296, 14%). Mortality rates for infants with negative blood cultures, monomicrobial sepsis, and polymicrobial sepsis were 1.5% (5099/332,884), 11% (1775/15,623), and 13% (31/247), respectively. Polymicrobial sepsis that involved Candida was associated with the highest mortality (gram-negative/Candida, 3/10 [30%], and gram-positive/Candida, 6/23 [26%]). Mortality involving gram-negative/ gram-negative infections was 7/43 (16%), gram-negative/gram-positive was 9/88 (10%), and gram-positive/gram-positive was 6/83 (7%). On multivariable regression, increasing birth weight (OR 0.46 [95% CI 0.28–0.76], p < 0.01) and increasing gestational age (OR 0.89 [0.82–0.97], p < 0.01) were associated with a decreased risk of polymicrobial sepsis, and need for mechanical ventilation on day of life 1 (OR 3.56 [2.35–5.39], p < 0.01) was associated with a higher risk of polymicrobial sepsis. Discussion: This study presents predictors of infection and outcomes for the largest cohort of infants with polymicrobial BSIs to date. Low gestational age, low birth weight, and need for mechanical ventilation on day of life 1 were associated with development of polymicrobial sepsis. Mortality associated with polymicrobial sepsis was lower in this cohort of infants (13%) than previously reported. A12 The Piedmontese Regional Referral Center for the management of retinopathy of prematurity: a 6-year report M. Brandozzi1 , E. Giacosa1 , G. Garbo2 , G. Anselmetti1 . 1 Ophthalmology Department Regional Referral Center for ROP, Torino, Italy; 2 Neonatal Intensive Care Unit. Maria Vittoria Hospital, Torino, Italy Aim: To study ROP features in infants of any gestational age affected by ROP evaluated in the last 6 years in our Regional Referral Center for retinopaty of prematurity. Material and Methods: A retrospective review was performed on all the patients (175) with diagnosis of ROP who were referred to our Regional Referral Center from 2006 to 2011 and who received further diagnostic evaluation and – in selected cases – surgical or laser treatment. Results: A total of 175 patients affected by ROP were evaluated in our Center. Their mean gestational age was 25.7+2SD weeks (range