Indian Journal of Neonatal Medicine & Research

Achromobacter xylosoxidans Causing Late-onset Sepsis with Pneumonia in a Term Neonate

Basany Laxman, Aepala Roja

Achromobacter xylosoxidans (A. xylosoxidans), is an aerobic gram negative motile bacillus that rarely causes infection in healthy adults and is exceptionally rare in neonates. A. xylosoxidans is ubiquitous in nature, causing nosocomial infections especially in debilitated and immunocompromised patients. Few outbreaks caused by this organism were reported in Neonatal Intensive Care Units (NICU) along with sporadic cases in neonates. A 3-week-old term neonate presented with late-onset sepsis and pneumonia caused by A. xylosoxidans that was successfully treated with antibiotics and supportive care. Awareness regarding this uncommon pathogen and initiation of appropriate antibiotic therapy would improve the outcome and prevent mortality.

Association and Outcome of Intracranial Haemorrhage in Newborn with Fungal Sepsis- A Prospective Cohort Study

Introduction: Neonatal sepsis is a leading cause of mortality and morbidity. Inspite of using appropriate antibiotics, those who are bacterial culture-negative, still succumb to fungal infection. Fungal sepsis is common in the neonatal Intensive Care Unit (ICU), especially with invasive procedures and prolonged empirical use of antibiotics. The incidence of fungal infection varies widely across centers, likely due to differences in practice related to modifiable risk factors such as exposure to empiric antibiotics and length of parenteral nutrition. Neonates are at high risk for acquiring infections due to their specific Central Nervous System (CNS) structure as well as functionally immature immune system causing central nervous system infection or intracranial haemorrhage due to sepsis induced coagulopathy. Being Intracranial Haemorrhage (ICH) in neonates often results in devastating neurodevelopment outcome and also having significant mortality in the neonatal period. Aim: To find the association and outcome of intracranial haemorrhage in newborn with fungal sepsis. Materials and Methods: This study was a prospective cohort study conducted at Department of Pediatrics, Government Kilpauk Medical College, Chennai, Tamil Nadu, India, on neonates admitted in newborn ward of the hospital ICU during the period January 2018 to December 2020. Neonates with the diagnosis of fungal sepsis were identified from blood cultures. They were also subjected to Complete Blood Count (CBC), Capillary Refilling Time (CRT), Prothrombin Time (PT), activated Partial Thromboblastin clotting time (aPTT) and cranial ultrasound. Chi-square analysis for descriptive data and Cox Proportional Hazard Regression for survival and non survival neonates and Kaplan-Meier curve analysis was done. Results: Out of total 80 neonates, nine had intracerebral haemorrhage, 21 neonates had intraventricular haemorrhage and no haemorrahge in 50 neonates. More the gestational age, lesser were the chances of intracranial haemorrhage and the difference was statistically significant (p-value<0.001). A total of 50 babies died, majority (42%) were in the gestational age between 37-40 weeks. All the babies diagnosed with C. albicans sepsis succumbed to infection. Conclusion: The present study highlights the fact that the lesser of the gestational age, the more or the chances of intracranial haemorrhage. A close monitoring of the coagulation profile PT and aPTT will help us to identify the babies for more prone for intracranial haemorrhage. Expert cranial ultrasound will pick up the haemorrhage early. Timely treatment measures instituted will help in preventing mortality due to bleeding manifestions in fungal sepsis. The Cox regression analysis reveals that both PT& aPTT and intracranial haemorrhage are the associated risk factors for non survival in fungal sepsis neonates.

Perinatal Outcome with Isolated Oligohydramnios in Term Pregnancies: A Case-control Study from a District Hospital of Southern India

Cheruku Amani, Sowmya Gopinath, Suman Meenakshi Gururaja

Introduction: Oligohydramnios is an abnormality of amniotic fluid which is one of the common complications during pregnancy and a threat to foetal development. Often it is associated with maternal risk factors like uteroplacental insufficiency, hypertension and preeclampsia which by themselves can affect perinatal outcome. Aim: To determine the perinatal outcome in isolated oligohydramnios with Amniotic Fluid Index (AFI) ≤5cm at term pregnancies. Materials and Methods: This was a hospital-based prospective case-control study done in Department of Obstetrics and Gynaecology at District Hospital Tumakuru, Karnataka, India, from January 2019 to July 2020. The study included two groups i.e, case group included 150 pregnant females with Amniotic Fluid Index (AFI) ≤5 cm and control group included 150 pregnant females with AFI range between 6-24 cm. After interview of all participants, all the information was entered in the proforma. All newborn babies birth weight, APGAR scores (Appearance, Pulse, Grimace, Activity, and Respiration) at 1^st and 5^th minute was recorded. Categorical outcomes were compared between the groups using Chi-square test. A p-value <0.05 was considered statistically significant. Results: The mean age was 23.16±3.09 years in case group and it was 23.42±2.99 years in control group, the difference of age between study group was statistically not significant (p-value=0.460). Abnormal doppler in 19.33% of cases versus 6% of controls (p-value<0.001). Non reactive Non Stress Test (NST) was seen in 46.67% versus 10.67% in control group (p-value<0.001). The foetal distress as a cause for caesarean section was seen in 64.8% cases group in comparison with 23.9% of control group. Low birth weight was found in 58.67% of cases versus 30% in control groups (p-value<0.001). Low APGAR scores (<7) were seen in 24.67% of case group versus 5.33% in control groups. The difference in the proportion of APGAR score at 5 minutes between study group was statistically significant (p-value<0.001) Neonatal intensive care unit admissions were seen in 42.67% of cases versus 12.67% in controls (p-value<0.001). Perinatal deaths was in 5.33% in cases versus 0.67% in controls (p-value=0.017). Conclusion: Isolated oligohydramnios was a significant risk factor during term pregnancies. Incidence of operative deliveries (instrumental vaginal delivery and caesarean section) is significantly increased in these patients with significant increase in perinatal morbidity and mortality.

Quantitative Analysis of Thrombocytes in Neonates in a Tertiary Care Centre of Southern India- A Retrospective Study

Y Lakshmi Pravallika, S James Daniel, VR Sudha Reddy

Introduction: Thrombocytopenia is defined as a platelet count of less than 150×10⁹/L, which is also applicable to newborn infants. It may be a result of increased platelet destruction (immune and non immune), decreased platelet production, and a combination of both or unknown. A platelet count of more than 500×10⁹/L is considered thrombocytosis, classified as primary or essential and secondary or reactive. Abnormal platelet count being quite common, is most often neglected and it can lead to devastating complications if untreated. Aim: To study the incidence of abnormal platelet counts and to determine the risk factors associated with abnormal platelet counts in neonates admitted to the Neonatal Intensive Care Unit (NICU). Materials and Methods: A retrospective analysis of platelet count of all neonates admitted to a tertiary NICU of RL Jalappa Hospital, Tamaka, Karnataka, India, between July 2020 and June 2021 was done to determine the incidence and risk factors associated with abnormal platelet count (thrombocytopenia and thrombocytosis). Data of all the neonates were collected retrospectively from July 2021 to August 2021 and analysed. A total of 562 neonates were included in the study. Categorical data was taken and expressed in the form of frequencies and percentages. Data were entered as frequencies using Microsoft excel version 2203 and analysed using Statistical Package for Social Sciences (SPSS) software version 22.0. Chi-square and Fischer’s exact test were used to determining the significance of the data. The p-value <0.05 was considered statistically significant. Results: Out of 629 neonates admitted, 562 neonates were included in the study. Total 209 neonates had thrombocytopenia, with early thrombocytopenia being in 94 (45%) and late being in 115 (55%). Thrombocytosis was seen in only 15 neonates where 7 (46.6%) had early, and 8 (53.3%) had late thrombocytosis. The most common risk factor associated with both cases was sepsis. Placental insufficiency had a statistically significant association with thrombocytopenia (p<0.001**). Term babies had a higher incidence of thrombocytopenia and thrombocytosis, and the association with thrombocytopenia was statistically significant (p=0.043*). Conclusion: Based on the present study, it can be concluded that abnormal platelet count is quite a common finding in sick neonates. Thrombocytopenia is more common than thrombocytosis. The most common risk factor is sepsis, it should not be neglected, and appropriate treatment should be initiated once an abnormal platelet count is detected in neonates.

Aetiological Agents in Neonatal Nosocomial Sepsis and their Sensitivity Pattern from a Tertiary Care Hospital, Odisha, India: A Cross-sectional Study

RK Shwetabh, Manas Ranjan Upadhyay, Rajlaxmi Upadhyay

Introduction: Nosocomial infections are a major problem for hospitalised neonates due to increase in morbidity, mortality, duration of hospitalisation and costs of treatment. The magnitude of this problem varies from place to place and is unique to each place as per the organisms and their resistance pattern is concerned. There is need to develop local level surveillance data on incidence of nosocomial sepsis, causative organisms, their sensitivity pattern and periodically review antibiotic policy based on this information. Aim: To determine the aetiological agents of nosocomial sepsis and their antibiotic sensitivity and resistance pattern. Materials and Methods: This was a cross-sectional study in which the cases of nosocomial infections in neonates of > 35 weeks were studied from November 2018-October 2019 at Sriram Chandra Bhanja Medical College and Hospital (S.C.B.M.C.H) and Sardar Vallabh Bhai Patel Postgraduate Institute of Paediatrics (S.V.P.P.G.I.P) based on clinical findings, sepsis screen and blood culture. Blood culture is considered as gold standard for diagnosis of sepsis. Blood sample (1 mL) was collected under strict asepsis in Becton Dickinson and Company (BACTEC) and was sent for performing blood culture. The data was processed and arranged into distribution tables and cross tables using Statistical Package for the Social Sciences (SPSS) version 21.0. Results: Out of total 100 suspected cases of nosocomial sepsis, blood culture was positive in 46 (46%) of cases. Candida spp. was the most common obtained organism 9 (19.5%) followed by Klebsiella pneumoniae 8 (17.3%) and Staphylococcus aureus 8 (17.3%) each respectively. There was increased incidence of bacterial resistance to commonly used antibiotics and combinations of it, like ampicillin, gentamicin, cefotaxime, amikacin and piperacillin+ tazobactam among these bacterial isolates. Among the possible new combinations deduced from the observation, the combination of vancomycin+amikacin had sensitivity of 67.6% and can be considered as initial antibiotic combination of choice while combination with colistin and tigecycline should be reserved only for culture proven resistant cases or babies who continue to be deteriorating and critically sick while on previous combination. Conclusion: Candida spp. is the leading cause of nosocomial sepsis. Among bacterial organisms, Klebsiella pneumoniae and Staphylococcus aureus are most common. Most isolates are resistant to traditional antibiotics, hence new combination like vancomycin+amikacin are more appropriate empiric choice in present context and combination with colistin and tigecycline are reserved only for culture proven resistant sepsis.

Short Term Assessment of Growth and Neurodevelopmental Outcome in Low Birth Weight and Very Low Birth Weight Newborns Discharged from A Tertiary Care Centre-A Cohort Study

Swasthi Kabi Satpathy, Manas Ranjan Upadhyay, Rajlaxmi Upadhyay

Introduction: With better healthcare facilities, despite an increase in neonatal survivor rates, the outcomes in the survivors still remains uknown to a great extent. In overburdened centres following an early discharge policy, a structured follow-up plan to evaluate growth, development and problems faced by the high-risk babies is essential. Aim: To assess the growth, development at 52 and 64 weeks Post Menstrual Age (PMA) and association of postnatal growth failure with developmental outcome in Low Birth Weight (LBW) and Very Low Birth Weight (VLBW) babies. Materials and Methods: This was a prospective cohort study carried out amongst the newborn babies discharged from a tertiary care hospital, Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India. within 2 months period and followed-up till 64 weeks PMA. Out of 189 newborns discharged during study period, 168 met the inclusion criteria and only 114 babies could complete the follow-up till 64 weeks postmenstrual. The weight, length and head circumference were documented at discharge, 44, 52 and 64 weeks PMA and compared using INTERGROWTH 21^st postnatal standards. Denver Developmental Screening Test was used for developmental screening at 52 and 64 week PMA. Descriptive analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0 and categorical data was compared using Chi-square test in trend using Epi Info software. Results: Out of 114 patients, 51 (44.7%) were females and 63 (55.3%) were males. At birth, 72 (63.16%) of study population was below 10^th centile which increased to 77 (67.54%) at 44 weeks PMA. By 64 weeks PMA, 62 (54.39%) infants were showing catch up. Out of total, 18 (15.79%) showed delayed developmental milestones. 11 out of 18 (61.11%) babies were with delayed development, i.e., below 3^rd centile of weight for age showing that at lower postnatal weight odds of patients having developmental delay were increased. Conclusion: Postnatal growth pattern of the study population was along the lower centiles of INTERGROWTH 21^st chart. Incidence of developmental delay was higher in babies with postnatal growth failure.

Clinical Profile and Outcome of Multisystem Inflammatory Syndrome in Children (MIS-C): A Retrospective Study

Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a life-threatening complication of SARS-CoV-2 infection. It can also present with multisystem involvement including circulatory shock, systemic inflammation, and mucocutaneous and dermatologic involvement. Children infected with Coronavirus Disease-2019 (COVID-19) are mostly asymptomatic but those having co-morbidities are at a greater risk of getting severe infections. Aim: To study the clinical profile and outcome of children with MIS-C. Materials and Methods: This was a single-centre retrospective hospital-based observational study conducted at Indira Gandhi Goverment Medical College, Nagpur, Maharashtra, India. MIS-C protocol was developed at the Institutional level as per the World Health Organisation (WHO) and Indian Academy of Paediatrics (IAP) guidelines. Children admitted with MIS-C upto the age 18 years, were included as per the diagnostic criteria of MIS-C given by the WHO. The data pertaining to the demographics, clinical findings, underlying comorbidities, echocardiographic findings, laboratory investigations, and treatment received including intensive care interventions and outcomes were obtained from patient hospital records from 1st May 2021 to 30th September 2021.These collected data were obtained and statistical analysis was performed in patients treated for MIS-C. Results: The study included 18 children, who were diagnosed with MIS-C, with a median age of 6 years. Most of them presented with fever 12 (66.67%), followed by gastro intestinal symptoms 11 (61.1%). Elevated levels of C-reactive protein were found in all of them (58.04±34.87mg/L). The majority of children needed intensive care admissions (17, 94.45%) and vasoactive medications were given to 8 (44.45%) children. Steroids were given in all children and Intravenous Immunoglobin (IVIG) in 7 (38.9%), and a combination was used in 10 (55.55%) children. Co-morbidities were seen in 4 (22.22%) children (2 sickle cell disease, 1 diabetes mellitus type 1, and 1 had global developmental delay. Mortality was noted in 4 (22.22%) children, and none of them had any co-morbidities. Conclusion: The majority of the children with MIS-C in this study presented with acute febrile illness and shock and required intensive care. In children with pre-existing comorbidities, the outcome is surprisingly good.