Indian Journal of Neonatal Medicine & Research

Reduction of Antibiotics Used in Newborn Babies Admitted to Neonatal Unit: A Quality Improvement Initiative

Introduction: Excess exposure of antibiotics early in life disrupts the developing microbiome in skin and gastrointestinal system of new born which may lead to development of different health conditions. Prolong use of antibiotics in Neonatal Intensive Care Unit (NICU) develops resistance to infection, increases risk of Necrotizing Enterocolitis (NEC) and invasive fungal infection in new born. Studies reported that short course of antibiotics prevent treatment failure, cause reduction of duration of hospital stay, prevent antimicrobial resistance, decrease neonatal mortality and improve neurological outcome. Aim: This Quality Improvement (QI) study aimed to establish a standard guideline for reduction of antibiotics use in new born unit of a tertiary level health care institution of India. Materials and Methods: This QI study was conducted in the newborn units of paediatrics department of a tertiary health care center, Odisha, India, from 1st June to 31st July, 2018. Patients, under antibiotic therapy, were enrolled in this study. The data were collected in a predesigned case record form regarding duration, indications (as per the minimal investigation for sepsis, as per minimal risk factor for antibiotics used, as per high index of suspicion) and outcome in terms of cured, death and LAMA (Leave Against Medical Advice). Baseline data regarding the use of antibiotics were collected for one month period and final data for another one month were collected after applying newly formed antibiotic use guideline among neonates. Data were analysed by Chisquare test using Graph pad prism ver. 0.5. Results: In this study distribution of antibiotic used among hospitalised patients in post-intervention phase was significantly decreased (77%) compared to baseline data (94%). This study result showed that percentage of cases using antibiotics, were not as per risk factors and were reduced significantly, post implementation of guidelines. Antibiotic used, as per the high index of suspicion increased (76%) significantly compared with baseline data (27%) and also as per the systemic sign of sepsis increased significantly in final data (74.04%) over baseline data (48%). Antibiotic use duration was reduced in post-intervention period i.e., =3 days over =5 days (baseline data) significantly. There was no significant difference in outcomes. Conclusion: On application of newly formed antibiotic use guideline with reduced antibiotic use strategy, the final data compared with baseline data did not show any significant difference in cure rate as well as death/LAMA/referred.

Liver Dysfunction in Perinatal Asphyxia

Jaswir Singh, Anil Kumar Poonia

Introduction: Liver dysfunction in perinatal asphyxia may be manifested by elevation of hepatocellular enzymes. It affects the outcome of perinatal asphyxia in newborn. Aim: To study the effect of perinatal asphyxia on liver function. Materials and Methods: This study was conducted on 100 newborns with perinatal asphyxia and 50 healthy newborns were taken as control group. Baby with APGAR score <7 at 1 minutes, fetal heart variation and meconium passage in utero were considered to have perinatal asphyxia. Qualitative data was analysed statistically by Person ChiSquare test. Numerical analysis was done by mean, SD and independent t-test. Results: The study included 59 male babies and 41 female babies in the case group and 25 male babies and 25 female babies in control group. Mean gestational age in case group was 37.29±2.1 weeks and in control group was 37.06±2.25 weeks. The difference between perinatal asphyxia and control group was highly significant for Serum Glutamate Oxaloacetic Transaminase (SGOT), Serum Glutamate Pyruvic Transaminase (SGPT) and Alkaline Phosphatase (ALP) (p<0.001) and significant for Total Serum Bilirubiun (TSB) (p<0.025). The difference between fetal asphyxia alone and control group was highly significant (p<0.001) for SGOT, SGPT and significant for ALP (p=0.002) and TSB (p=0.009) respectively. In birth asphyxia alone group, the difference was highly significant for SGOT, SGPT, ALP (p<0.001) and significant for TSB (p=0.034) as compared to control group. Conclusion: Early detection of hepatic dysfunction helps to predict the complication of hepatic dysfunction and their early treatment.

Bacterial Isolates in a Neonatal Intensive Care Unit-A Rural Perspective

Introduction: Bacterial sepsis is one of the most common causes of mortality and morbidity in neonates. The spectrum of bacteria that cause neonatal sepsis varies and antibiotic resistance is an increasing problem for these bacteria. Aim: 1) To study the bacteriological profile in the neonates admitted in the Neonatal Intensive Care Unit (NICU) of a tertiary care teaching hospital. 2) To determine the antibiotic sensitivity pattern of the same so that appropriate antibiotics can be chosen to improve the treatment and asepsis. Materials and Methods: This was a retrospective observational study which was conducted in the NICU of a tertiary teaching hospital. All symptomatic neonates up to 28 days old admitted in NICU were included in this study. A total of 118 samples were sent for cultures. The data was obtained from the Neonatal ICU registers, Medical Department Records and Microbiology laboratory records. Results: In this study, 118 neonates were considered and depending upon the inclusion criteria those having neonatal sepsis and were admitted to the NICU were taken. The risk of having growth in preterm neonates is 2.27 times more than that in full term neonates. Prevalence of Microbial growth was highest in neonates who were less than 2 kg in birth weight i.e. very low birth weight babies. Microbial growth in neonates admitted within 3 days of life was 1.273 times more than that in neonates who were admitted after 3 days of life. Positive co-relation was seen between microbial growth and who stayed in the hospital for more than seven days. Out of 118 isolates, 80 had no growth, 13 showed MRSA positive, 9 were positive for Staphylococci, 8 were for Klebsiella, 3 Gram negative bacilli, 2 Citrobacter and 1 remaining. Conclusion: In view of the changing spectrum of the causative agents of neonatal septicaemia and antibiotic sensitivity and resistance pattern from time to time, a positive blood culture and the antibiotic sensitivity and resistance pattern testing of the isolates are the best guide to the antimicrobial therapy which would be beneficial to the best outcome of the disease.

Comparing the Effect of Room Air versus Commercially Available Oxygen for the Resuscitation of Asphyxiated Neonates in Kabul City: A Randomised Clinical Trial

Mansoor Aslamzai, Mohammad Farouq Hamidi, Zemary Hassin

Introduction: Perinatal asphyxia is one of the leading causes of neonatal death in Afghanistan. Recent recommendation has accepted room air as preferred therapy in the resuscitation of asphyxiated term neonates. Since the quality of air is poor in Kabul city so a study was needed to assess its efficacy in the resuscitation of neonates. Aim: To evaluate the effectiveness of room air versus commercially available oxygen for the resuscitation of asphyxiated term and preterm neonates. Materials and Methods: This study was a randomised clinical trial conducted at Neonatology ward of Malalai Hospital in Kabul city, Afghanistan. Total 300 neonates of 30-41 weeks gestation diagnosed as severe perinatal asphyxia were randomly resuscitated with either room air or commercially available oxygen. The clinical parameters were the Apgar score, oxygen saturation and neonatal mortality percentage. Statically analysis was performed by SPSS 20. Results: One hundred and fifty neonates in the room air group and 150 neonates in commercially available oxygen group were investigated. The term neonate percentage was 76% and 75.3% in the room air and oxygen group respectively. Term neonates resuscitated with room air had obtained higher mean oxygen saturation (83.4±14.9, p=0.001) than oxygen (77.1±13.1, p=0.001) at 5 minute of birth. Median Apgar score was the same in both groups (5, p=0.001). The difference of mortality during hospital stay in both groups was not statistically significant (5.26% vs 7%, p=0.59). Mean oxygen saturation in preterm newborn babies were 80.58±15.62 and 78.41±11.91 with p=0.22, respectively in both groups. Median Apgar score in room air was 6 and in oxygen group was 5 with p=0.33. Preterm infant also showed non-significant difference of mortality during hospital stay in both groups (11.1% vs 18.9%, p=0.5). Conclusion: Despite poor air quality in Kabul city, room air was significantly more effective than commercially available oxygen to increase oxygen saturation and as effective as commercially available oxygen to elevate Apgar scores in the resuscitation of asphyxiated term neonates. The difference in the mortality was not statistically significant in both the groups. The efficacy of room air did not appear statistically significant for the resuscitation of preterm neonates.

Clinical Spectrum of Nephrotic Syndrome and Correlation with Histopathology and Immunofluorescence Findings

S Indupriya, Sridhar Yerram, Chakravarthula Anupama

Introduction: Nephrotic syndrome is characterised by altered permselectivity of the glomerular filtration barrier which is a common chronic renal disorder in children. In children, it is characterised by oedema, hypoalbuminemia and proteinuria. Aim: To study the clinical profile of nephrotic syndrome in patients and also to study histopathological and immunofluorescence findings and correlation with clinical response to treatment. Materials and Methods: A prospective clinical study was undertaken to study the ‘Clinical Spectrum of Nephrotic Syndrome with special reference to Histopathology and Immunofluorescence. Children with nephrotic syndrome upto the age group of 18 years admitted in the Nephrology ward over a period of one year from January 2008 to December 2008 were included. All patients who met the criteria for nephrotic syndrome (proteinuria >40 mg/m2 /hr serum albumin <2.5 gm/dL, serum cholesterol >200 mg/dL) were eligible for the study. The results were analysed based on the clinical profile histopathology and immunoflorescence findings of the cases. Results: A total of 72 cases with Nephrotic syndrome were included in this study, gross haematuria was noticed in 9 cases (12.5%), hypertension was noticed in 21 cases (29.2% of children).Upper Respiratory Tract Infection (URTI) was seen in 34 cases (77.27%), Urinary Tract Infection (UTI) seen in 03 cases (06.81%), viral fever was seen in 9 cases (12.5%), peritonitis seen in 3 cases (4.2%) and it was seen as the precipitating causes for relapse. Hypertension was seen in 46 cases (63.6%) of steroid resistant group and 24 hour urine protein excretion was more in steroid resistant group. Renal biopsy was done in 29 out of 72 children (42.7%). Minimal change nephrotic syndrome was seen in 11 cases (37.9%) that underwent biopsy irrespective of the indication. Mesangio-proliferative nephrotic syndrome was the most common type in non minimal change nephrotic syndrome, 13 cases (45%) out of 18 cases of nonminimal change nephrotic syndrome (62%). Conclusion: Immunofluorescence is very important in diagnosing secondary nephrotic syndrome and plays a very important role where light microscopy alone cannot help in diagnosis such as IgA and IgM nephropathy, and Lupus nephritis.