Antibiotic use in neonates. Protocols , Rationale, Antibiotic stewardship and newer agents, NICU microbiological profile. A grand presentation by Dr. Maskey in TUTH.
Definition of neonatal sepsis,type of neonatal sepsis ,early onset neonatal sepsis,late onset neonatal sepsis,Pathophysiology of neonatal sepsis,,sign and symptoms of neonatal sepsis, diagnosis of neonatal sepsis,management of neonatal sepsis, antibiotic used for neonatal sepsis,prevention of neonatal sepsis, prognosis of neonatal sepsis ,and A summary
Definition of neonatal sepsis,type of neonatal sepsis ,early onset neonatal sepsis,late onset neonatal sepsis,Pathophysiology of neonatal sepsis,,sign and symptoms of neonatal sepsis, diagnosis of neonatal sepsis,management of neonatal sepsis, antibiotic used for neonatal sepsis,prevention of neonatal sepsis, prognosis of neonatal sepsis ,and A summary
Management of hypoxic ischemic encephalopathy (HIE) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management of hypoxic ischemic encephalopathy (HIE) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Management of hypoxic ischemic encephalopathy (HIE) by Sunil Kumar Dahasunil kumar daha
Please find the power point on Management of hypoxic ischemic encephalopathy (HIE) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Long segment urethral strictures with a very narrow lumen pose an immense challenges for buccal mucosa augmentation urethroplasty.
Larger discrepancy in size of the graft and the native urethral plate makes it difficult to place the sutures and also makes the graft vulnerable to contracture and fibrosis.
Increasing the width of the urethral plate by a vertical midline mucosal incision and applying an additional inlay buccal mucosal graft may lessen the discrepancy and help in improving the adequacy of the urethral lumen.
Other option to deal with these kind of strictures is dorsal onlay and ventral inlay.
Spongiofibrosis is never full thickness except in traumatic injury ( straddle injury/blunt trauma)
Partial thickness Spongiofibrosis and scarred mucosa can be removed completely and replaced by buccal mucosa.
Lithotomy position
Epidural + general anesthesia.
Vertical perineal incision. Mobilization of bulbar urethra
Dorsal ( one side kulkarni’s technique)or ventral urethrotomy
Vertical midline incision or complete removal of scarred urethral plate with removal of thin layer of spongiofibrosis.
Inlay and onlay grafting done
Urethra closed over 16 fr
Results were analysed on the basis of pre and post operative uroflowmetry.
Any kind of instrumentation was considered as failure.
Mean follow up 630 days.
22 patients have significant better flow rate after surgery
One patient developed ring stricture near proximal anastomosis and managed by urethral dilatation.
One patient developed abscess followed by urine leak and was managed conservatively with indwelling catheter and antibiotics.
Combined urethroplasty avoid complete transection of urethra.
It widens the native urethral plate in an anatomical manner
Reduces the disparity between urethral plate and onlay buccal mucosa.
improves the success rate of long and very narrow bulbar urethra strictures
Antibiotics are crucial tools in surgery and there use has seen drastic reduction in morbidity and mortality in surgical patients. They are however only adjuncts to established surgical principles of sepsis and anti sepsis, and source control of infection.
Antimicrobial resistance is the ability of a microorganism (like bacteria, viruses, and some parasites) to stop an antimicrobial (such as antibiotics, antivirals, and antifungals) from working against it.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Dr. Mike Apley - Antibiotics in the Future Tense: How the Last 5 Years Have S...John Blue
Antibiotics in the Future Tense: How the Last 5 Years Have Set the Course - Dr. Mike Apley, College of Veterinary Medicine, Kansas State University, from the 2017 Minnesota Pork Congress, January 17 - 18, 2017, Minneapolis, MN, USA.
More presentations at http://www.swinecast.com/2017-minnesota-pork-congress
Growth charts in Neonates- Preterm and termSujit Shrestha
Growth charts in Newborn, Preterm and term neonates. All historically used charts in NICU are discussed here.
Presented by Dr Sujit, in Sir Ganga Ram Hospital
The newer antibiotics added to Our Arsenal against resistant bacteria. Know about the upcoming antibiotics and newer antibiotics in use.
Free text at
http://medchrome.com/basic-science/pharmacology/newer-antibiotics-review/
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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1. Rational antibiotic use in
newborn
Nischal Maskey
Department of Child Health
Mahrajgunj Medical Campus, IOM
2. Contents
• Introduction to rational use of medicine
• Effect of antibiotics on neonates
• Clinical data
• Overview on antibiotics
• NICE guidelines on sepsis
• Choice and duration of antibiotics
• Prophylactic antibiotic use
3. Definition
• Rational use of medicines refers to the
correct, proper and appropriate use of
medicines. Rational use requires that patients
receive the appropriate medicine, in the
proper dose, for an adequate period of
time, and at the lowest cost to them and their
community. (WHO)
4. What are the consequences of
incorrect use of medicines?
• Antimicrobial resistance.
• Adverse drug reactions and medication errors
• Lost resources
• Eroded patient confidence
5. What factors contribute to incorrect
use of medicines?
• Lack of skills and knowledge
• Inappropriate unethical promotion of medicines
by pharmaceutical companies
• Profits from selling medicines
• Unrestricted availability of medicines
• Overworked health personnel
• Unaffordable medicines
• Lack of coordinated national pharmaceutical
policy
6. What can be done to improve rational
use of medicines?
• A national body to coordinate policies on medicine use
and monitor their impact
• Evidence-based clinical guidelines for
training, supervision and supporting decision-making
about medicines
• Drug (medicines) and therapeutics committees in
districts and hospitals to monitor and implement
interventions to improve the use of medicines
• Problem-based training in pharmacotherapy and
prescribing in undergraduate curricula
• Continuing medical education as a requirement of
licensure
7. • Publicly available independent and unbiased
information about medicines for health
personnel and consumers
• Public education about medicines
• Elimination of financial incentives that lead to
improper prescribing, such as prescribers selling
medicines for profit to supplement their income
• Regulations to ensure that promotional activities
meet ethical criteria
• Adequate funding to ensure availability of
medicines and health personnel.
8. Introduction
• Antibiotics are the commonest drugs used in the
NICU.
• Virtually all extremely low birth weight infants
receive antibiotics and for all other birth weight
groups admitted to the NICU the vast majority
are treated with antibiotics
• Only a small number eventually have culture
proven infection. Clark et al : 98% of preterm
infants who received empiric antibiotics were
culture negative.
9. Effect of antibiotics on the neonate
• Newborn: sterile gut.
• Normal flora: early days of life.
• Antibiotics : delay in microflora colonisation
with most anaerobes, importantly
Bifidobacterium and Lactobacillus.
• At 30 days of life Bifidobacterium and
Lactobacillus sp: 1/15 breastfed preterm
infants who had received antibiotics.
10. • Antibiotics also limit the number of bacterial
species in the normal flora.
• As few as 3 species in their flora at Day 10 of life
• An inverse dose- response between the duration
of antibiotics and the number of species in the
flora at Day 30 of life.
• Bacterial overgrowth of other species
• A major role in restricting the diversity and the
volume of the normal flora thus reducing
protection from invading pathogens.
11. • Animal studies : normal gut development is dependent on a diverse and
high volume flora and the normal flora also plays a significant role in the
physiological and immunodevelopment of the gut .
• Normal flora create a physical defence, a role in immune responses.
• Polysaccharide produced by Bacteroides fragilis : the cellular and physical
maturation of the gut.
• Bifidobacterium : immunomodulation, balance proinflammatory and anti-
inflammatory cytokine production in the gut resulting in a net
antiinflammatory response .
• Low bacterial counts and lack of diversity of anaerobes caused by
antibiotic use : necrotising enterocolitis (NEC).
12. Resistance and antibiotics
• Antibiotics alter the gut flora: colonisation
with resistant organisms.
• Resistance is usually to multiple drugs with a
higher mortality .
13. • One NICU : an empiric antibiotic regime of
tobramycin and penicillin for EOS and
tobramycin and flucloxacillin for LOS and the
second unit : cefotaxime and ampicillin.
• After 6 months the regimes were reversed.
Respiratory and rectal cultures were taken
weekly.
14. • Cefotaxime and ampicillin regime: RR=18 for
colonisation with resistant strains and this reversed
when the regimes were reversed.
• Four LOS occurred, 3 in the cefotaxime and ampicillin
group and one in the other group .
• Beta-lactam antibiotics : colonisation with
multiresistant organisms and regimes that restrict
the use of beta-lactam antibiotics reduce resistance.
15. • Use of aminoglycosides : not associated with
significant emergence of resistant organisms.
• Cefotaxime: association with increased mortality.
• A retrospective study of over 100,000 infants
given either gentamicin or cefotaxime with
ampicillin empirically in the first 3 days of life.
• The relative risk of mortality was increase 1.5
times for infants receiving cefotaxime.
Cefotaxime use may increase the risk of fungal
infection.
16. NICU TUTH ( 2070 Baisakh to Bhadra)
Acinetobactor (12.5%)
Staph aureus (40%)
CONS (15%)
Klebsiella (10%)
E Coli (12.5%)
Enterobactor (2.5%)
237 admissions: 30 cases of microbial growth (28 in blood/ 2 in ET tube)
26. Antimicrobial Stewardship
• Antimicrobial Stewardship is an activity that
promotes:
1. The appropriate selection of antimicrobials.
2. The appropriate dosing of antimicrobials.
3. The appropriate route and duration of
antimicrobial therapy.
27. • After confirming that the patient has a indication for
antimicrobial therapy, antimicrobial stewardship is the
8 R’s:
1. Right drug,
2. Right time
3. Right dose
4. Right route
5. Right resident
6. Right documentation
7. Right reason
8. Right response
28. • Core Members of the Antimicrobial Stewardship Team
• Infectious disease physician (Director or Co-director)
• Clinical pharmacist with infectious disease training (Co-
director or core member)
• Other members of the team
Microbiologist
Information system specialist
Infection control professional
Hospital epidemiologist
29. Antimicrobial Stewardship Program:
The Components
• Prospective audit with intervention and feedback
• Formulary restriction and preauthorization
• Education
• Guidelines and clinical pathways
• Antimicrobial order forms
• Dose optimization
• Parenteral to oral conversion
30. Amikacin Aminoglycoside antibiotic active against gram-negative bacilli,
especially Escherichia coli, Klebsiella, Proteus, Enterobacter,
Serratia, and Pseudomonas.
Ampicillin Penicillinase-susceptible β-lactam: gram-positive pathogens
except Staphylococcus; Salmonella, Shigella, Neisseria, E. coli, and
Proteus mirabilis
Aztreonam β-Lactam (monobactam) antibiotic with activity against gram-
negative aerobic bacteria, Enterobacteriaceae, and Pseudomonas
aeruginosa.
Carbenicillin Extended-spectrum penicillin (remains susceptible to penicillinase
destruction) active against Enterobacter, indole-positive Proteus,
and Pseudomonas.
Cefotaxime 3rd generation cephalosporin active against gram-positive and
gram-negative pathogens. No antipseudomonal activity.
Ceftazidime 3rd generation cephalosporin active against gram-positive and
gram-negative pathogens, including Pseudomonas aeruginosa.
31. Chloramphenicol Broad-spectrum protein synthesis inhibitor active against many
gram-positive and gram-negative bacteria, Salmonella,
vancomycin-resistant Enterococcus faecium, Bacteroides, other
anaerobes, Mycoplasma, Chlamydia, and Rickettsia; usually
inactive against Pseudomonas.
Ciprofloxacin Quinolone antibiotic active against P. aeruginosa, Serratia,
Enterobacter, Shigella, Salmonella, Campylobacter, N.
gonorrhoeae, H. influenzae, M. catarrhalis, some S. aureus, and
some Streptococcus.
Clindamycin Protein synthesis inhibitor active against most gram-positive
aerobic and anaerobic cocci except Enterococcus.
Cloxacillin Penicillinase-resistant penicillin active against S. aureus and
other gram-positive cocci except Enterococcus and coagulase-
negative staphylococci.
32. Gentamicin Aminoglycoside antibiotic active against gram-negative bacilli,
especially E. coli, Klebsiella, Proteus, Enterobacter, Serratia, and
Pseudomonas.
Imipenem-
cilastatin
Carbapenem antibiotic with broad-spectrum activity against gram-
positive cocci and gram-negative bacilli, including P. aeruginosa
and anaerobes.
Meropenem Carbapenem antibiotic with broad-spectrum activity against gram-
positive cocci and gram-negative bacilli, including P. aeruginosa
and anaerobes.
Metronidazole Highly effective in the treatment of infections due to anaerobes.
33. Ofloxacin Quinolone antibiotic for treatment of conjunctivitis or corneal
ulcers (ophthalmic solution) and otitis externa or chronic
suppurative otitis media (otic solution) caused by susceptible
gram-positive, gram-negative, anaerobic bacteria, or Chlamydia
trachomatis.
Penicillin G Penicillin active against most gram-positive cocci; S. pneumoniae
(resistance is increasing), group A streptococcus, and some gram-
negative bacteria (e.g., N. gonorrhoeae, N. meningitidis).
Piperacillin Extended-spectrum penicillin active against E. coli, Enterobacter,
Serratia, P. aeruginosa, and Bacteroides
Piperacillin-
tazobactam
Extended-spectrum penicillin (piperacillin) combined with a β-
lactamase inhibitor (tazobactam) active against S. aureus, H.
influenzae, E. coli, Enterobacter, Serratia, Acinetobacter, P.
aeruginosa, and Bacteroides.
34. Tigecycline Tetracycline-class antibiotic (glycylcycline) active against
Enterobacteriaceae, including ESBL producers; streptococci
(including VRE); staphylococci (including MRSA); and anaerobes.
Tobramycin Folic acid antagonist effective in the prophylaxis and treatment of
E. coli, Klebsiella, P. mirabilis, and Enterobacter urinary tract
infections; P. carinii pneumonia
Vancomycin Glycopeptide antibiotic active against most gram-positive
pathogens including Staphylococcus (including MRSA and
coagulase-negative staphylococci), S. pneumoniae including
penicillin-resistant strains, Enterococcus (resistance is increasing),
and C. difficile–associated colitis.
35. Gyawali N, Sanjana RK. Indian J Pediatr. 2013 May;80(5):371-4
Bacteriological profile and antibiogram of neonatal septicemia.
• 1,572 samples
• Blood culture was positive : 238 (15.13 %) samples.
• Gram positive and gram negative organisms were 44.1 % and
55.9 % respectively.
• Staphylococcus aureus : predominant isolate followed by Klebsiella
spp.
• Most of the gram positive isolates exhibited higher resistance to
penicillin and cephalosporin.
• Susceptibility : aminoglycosides and quinolones.
• More than two third isolates of gram negative Enterobacteriaceae
showed resistance to ampicillin.
• Third generation cephalosporin and aminoglycosides were found to
be more satisfactory among gram negative organisms as compared
to gram positive.
36. Shrestha S, Adhikari N, Rai BK, Shreepaili A. Antibiotic resistance pattern of bacterial
isolates in neonatal care unit. JNMA J Nepal Med Assoc. 2010 Oct-Dec;50(180):277-81.
• The positive yield of blood cultures was 19.56%.
• Most common: coagulase negative
Staphylococcus, Acinetobacter, Enterobacter and
non-haemolytic Streptococcus.
• A significant percent of the isolates were resistant
to the first line antibiotics.
• Gram negative: more than 30% are resistant to
cefotaxime and more than 50% are resistant to
gentamicin.
37. Shrestha S, Shrestha NC, Dongol Singh S, Shrestha RB, Kayestha S, Shrestha M, Thakur NK
Bacterial Isolates and its Antibiotic Susceptibility Pattern in NICU.
. Kathmandu Univ Med J (KUMJ). 2013 Jan-Mar;11(41):66-70.
• The blood culture yield : 44.13% with nosocomial sepsis - 10.79%.
• 84.08% early onset sepsis and 15.95% late onset sepsis.
• Klebsiella infection : commonest organism
• Gram positive organisms : 39.36% (Staphylococcus aureus then CONS)
• Gram negative organisms: 60.64% (Klebsiella followed by Pseudomonas)
• Klebsiella was 87.5% and 78.3% resistance to ampicillin and gentamycin
respectively.
• Gram negative isolates :87.5% and 77.2% were resistance to ampicillin and
gentamycin respectively.
• Among gram positive isolates 58.5% and 31.5% resistance to ampicillin
and gentamycin respectively.
• Resistance to cefotaxim to gram negative and gram positive isolates were
87.34% and 59.35% respectively.
38. Bhat Y R, Lewis LE, K E V.
.
Bacterial isolates of early-onset neonatal sepsis and their antibiotic susceptibility pattern between 1998 and
2004: an audit from a center in India. Ital J Pediatr. 2011 Jul 11;37:32. doi: 10.1186/1824-7288-37-32
• 2182 neonates screened, 389 (17.8%) positive blood cultures.
• Gram negative species 90.8% of culture isolates.
• Pseudomonas (33.2%) and Klebsiella (31.4%)
• Acinetobacter (14.4%), Staphylococcus aureus (9.2%), E.coli (4.4%),
Enterobacter (2.2%), Citrobacter (3.1%) and Enterococci (2.2%).
• In Gram negative group, best susceptibility was to Amikacin
(74.5%), followed by other aminoglycosides, ciprofloxacin and
cefotaxime. The susceptibility was remarkably low to ampicillin
(8.4%).
• Gram positive group: susceptibility of 42.9% to erythromycin, 47.6%
to ciprofloxacin and above 50% to aminoglycosides.
• Of all isolates, 83.8% were susceptible to either cefotaxime or
amikacin
39. NICE GUIDELINE ON EARLY
NEONATAL INFECTION
• Risk factors for infection
Pre-labour rupture of membranes
Preterm birth (<37 weeks), especially with pre-labour
rupture of membranes
Confirmed or suspected chorioamnioitis it is (e.g.
intrapartum fever)
Invasive GBS infection in a previous baby
Antibiotic treatment given to mother for confirmed or
suspected invasive bacterial infection 24 hours before,
during, or 24 hours post labour
40. Clinical Indicators Suggestive of
Infection
• Altered behaviour or responsiveness
• Altered muscle tone
• Feeding difficulties (e.g. feed refusal)
• Feed intolerance (e.g. abdominal distension, vomiting)
• Altered heart rate
• Signs of respiratory distress
• Oxygen desaturation
• Apnoea
• Signs of perinatal asphyxia or hypoxic ischaemia
• Seizures
• Need for mechanical ventilation (especially term baby)
41. • PPHN
• Temperature abnormality not explained by
environment
• Signs of shock
• Unexplained bleeding disorder ( e.g.
thrombocytopenia, INR <2)
• Oliguria
• Hypo/hyperglycaemia
• Metabolic acidosis (BE -10 or greater)
• Local signs of infection e.g. skin, eyes
• Confirmed or suspected sepsis in a co-twin
42. Red Flag Signs Suggestive of Neonatal
Infection
• Systemic antibiotics given to mother for
suspected bacterial infection within 24 hours
of birth
• Seizures
• Signs of shock
• Need for mechanical ventilation in a term
baby
• Suspected or confirmed infection in a co-twin
43. Actions
• Any red flags or no red flags but 2 or more risk
factors or clinical indicators, perform
investigations including blood cultures and
start antibiotics
44. • No red flag or clinical indicators but one risk factor or
no red flags or risk factors but one clinical indicator
1. Use clinical judgement and consider withholding
antibiotics
2. Monitor baby for clinical indicators of possible
infection, including the vital signs
3. Monitor for at least 12 hours from birth (at 1 hors, 2
hours and then 2 hourly for 10 hours)
4. If further clinical concerns perform investigations
including blood cultures and start antibiotics
45. • If a decision is made to give antibiotics aim to
start within 30 minutes and always within 1
hour of the decision
46. Choice of Antibiotics
• Use benzyl penicillin and gentamicin as first choice for
empirical treatment of suspected infection
• Benzylpenicillin
25mg/kg 12 hourly
50mg/kg 12 hourly if baby appears very ill
• Gentamicin
4.5 mg/kg
If a second does is to be given (see below) give 36 hours
after the first dose
The interval may be shorted based on clinical judgement
e.g. for gram –ve infection or if the baby appears very ill
47. Duration of antibiotic treatment
• Consider stopping after 36 hours
If initial clinical suspicion of infection was not strong and
CRP < 10mg/l on both tests and
Blood culture is negative and
The baby is well with no clinical indicators of possible
infection
• Treat for 5 days if
Strong clinical suggestion of infection
Continued clinical concerns about infection at 36 hours
CRP > 10 mg/l on either measurement
Positive blood culture
48. • Continue antibiotics beyond 5 days if
The baby did not fully recovered at 5 days or
This is advisable based on the blood culture
result and expert microbiological advice if
necessary
49. Meningitis
• If meningitis is suspected but gram stain is uninformative
use an antibiotic regimen based on local expert
microbiological advice
• Review treatment decisions taking into account subsequent
CSF results
• If CSF Gram stain suggest Group B Streptococcus give
benzyl penicillin 50mg/kg 12 hourly and gentamicin 4.5
mg/kg every 36 hours
• If culture confirms GBS continue benzylpenicillin for at least
14 days and gentamicin for 5 days
• If CSF Gram stain or culture suggests any organism other
than GBS. use an antibiotic regimen based on local expert
microbiological advice
50. • In a randomized study, Metsvaht et al.
• Ampicillin versus penicillin G both combined with gentamicin
in the empirical treatment of neonates ( = 2 8 3)
• The clinical failure rate was not different between the two
groups (14.1% versus 14.2%).
51. Choice and Duration of Antimicrobial Therapy for Neonatal Sepsis and Meningitis
International Journal of Pediatrics
Volume 2011 (2011)
• Based on current available evidence, the combination
of ampicillin and gentamicin is an appropriate choice
for empirical therapy of EOS in neonates, where GBS
and E. coli continue to be the predominant organisms.
• Expansion of antimicrobial spectrum and also offers
synergistic bacterial killing.
• Low cost and low rates of emergence of bacterial
resistance.
• In developing countries, empiric antibiotic therapy
should be based individualized for each hospital or
region.
52. Late onset sepsis
• CoNS : most common pathogen in LOS followed
by S. aureus, Enterococcus spp., and GBS; Gram-
negative organisms account for 18–20% of LOS.
• The empirical antimicrobial therapy : both Gram-
positive and Gram-negative organisms.
• In the developed countries, where CoNS is the
predominant nosocomial pathogen and where
resistance of these isolates to penicillin,
semisynthetic penicillin, and gentamicin are
common, experts recommend the use of
vancomycin as empirical therapy.
53. • Among 18 participating NICUs in Australasian study
group for neonatal infection, nine units used
vancomycin and an aminoglycoside as the first-line
empirical treatment for LOS
• Their mortality from CoNS sepsis was comparable to
ampicillin or flucloxacillin together with an
aminoglycoside.
54. • In developing nations, higher percentage of Gram-
negative bacteria and greater antimicrobial
resistance
• About 70% of these isolates may not be covered by
the empiric regimen of ampicillin and gentamicin.(
Zaidi et al)
• High proportion of methicillin-resistant S.
aureus (MRSA) strains in many areas, especially
south Asia (56%)
55. • The Cochrane review : study by Miall-Allen et al
• Timentin (ticarcillin and clavulanic acid)
monotherapy with a combination of flucloxacillin and
gentamicin in 28 neonates with suspected LOS
• No difference in outcome (mortality/treatment
failure) between the two groups.
56. • Inadequate evidence from randomized trials in favor
of any particular antimicrobial regimen for the
empirical treatment of suspected LOS.
• Vancomycin and third-generation cephalosporin
(e.g., cefotaxime) : cardiorespiratory instability and in
areas where MRSA is prevalent.
• Vancomycin as the initial therapy: emergence of
vancomycin-resistant enterococci and its overuse in
cases where CoNS isolates represent mere
contaminants.
57. Duration of antibiotic therapy
• The duration of antimicrobial therapy for
culture-proven sepsis depends on the initial
response to the appropriate antimicrobial
agent.
• Paucity of RCTs evaluating the rationale and
safety of the appropriate duration of therapy
58. • Engle et al. randomized cases of neonatal pneumonia
to either 4-day or 7-day course of antibiotics.
• Randomization was done on day 4 of antibiotic
therapy if the infants were completely asymptomatic
for at least 48 hours.
• The success of therapy was similar in both the groups
59. • Chowdhary et al. compared the effectiveness of 7-day
versus 14-day antibiotic therapy in 69 infants with
blood culture-proven bacterial sepsis.
• Randomization on day 7 of antibiotics if the infant had
clinical remission by day 5.
• More treatment failures in 7-day group
• Treatment failures occurred in subjects with S.
aureus infection receiving 7-day course
60. • Gathwala et al.
• 10-day versus 14-day course culture-proven neonatal
sepsis
• Sixty infants were included.
• Clinical remission with negative C-reactive protein
(CRP).
• Cefotaxime and amikacin
• 10-day antibiotic therapy is as effective as 14-day
therapy in blood-culture-proven neonatal sepsis, if the
infant has achieved clinical remission by day 7 of
therapy.
61. • There is limited evidence for infants with younger
gestational age (<32 weeks), who are at the highest risk
for sepsis.
• It is reasonable to treat for 10–14 days with
appropriate antimicrobial agents in infants with blood-
culture-proven sepsis.
• However, in selected situations (neonates ≥32 weeks
gestation and ≥1500 grams, who become
asymptomatic within 5 days of appropriate therapy),
consider stopping antibiotics at 7–10 days, provided
appropriate followup can be ensured.
62. Antimicrobial Choice and Duration of
Therapy for Neonatal Meningitis
• In 2004, Infectious Disease Society of America
1. EOS, ampicillin with either an aminoglycoside or
cefotaxime
2. Late-onset meningitis, a regimen containing an
antistaphylococcal antibiotic, such as nafcillin or
vancomycin, plus cefotaxime or ceftazidime with or
without an aminoglycoside is recommended
63. • The duration of antimicrobial therapy in the patient
with bacterial meningitis has often been based more
on tradition than on evidence-based data.
• GBS meningitis is usually treated for 14 to 21 days
• For uncomplicated neonatal meningitis caused by
Gram-negative bacteria, a minimum of 21 days is
recommended .
• However, these guidelines are not standardized and
the duration of therapy may need to be individualized
on the basis of the patient’s clinical response.
64. • Combination of ampicillin and cefotaxime or ampicillin
and aminoglycoside is appropriate for treatment of
suspected early-onset neonatal meningitis.
• For suspected late-onset meningitis, a combination of
vancomycin plus a third-generation cephalosporin is
recommended while awaiting CSF culture and
susceptibility results. The duration of antimicrobial
therapy for neonatal meningitis should be 14 to 21
days for GBS, ≥21 days for L.
monocytogenes meningitis, and minimum of 21 days
for Gram-negative meningitis.
65. Adverse Effects with Prolonged
Duration of Antibiotic Therapy
• A 19-center study of 5693 ELBW
• Infants with sterile cultures who began initial empirical
antibiotic treatment within the first 3 postnatal days
• Median duration of empirical antibiotic treatment was
5 days.
• Prolonged duration of antibiotic therapy defined as >5
days) was associated with NEC or death (OR 1.30) or
death alone (OR 1.46)
• Each additional day of antibiotic therapy was
associated with a 4% increase in the odds of NEC or
death, a 7% increase in the odds of NEC alone, and a
16% increase in the odds of death alone.
66. • A case-control study in single center.
• 124 NEC cases vrs 248 controls on the basis of
gestational age, birth weight, and year of admission.
• Each day of antibiotic exposure was associated with a
20% increase in the risk of NEC.
67. • Prolonged antibiotic therapy has also been
associated with LOS
• 5693 subjects, increased risk of the combined
outcome of LOS caused by organisms other
than coagulase-negative Staphylococcus or
death (4 days: OR: 1.32 ) (5 days: OR: 1.24)
68. Nosocomial sepsis
• Klebsiella spp. (39.6%), Pseudomonas aeruginosa
(11.3%) and Coagulase-negative staphylococci
(9.4%). Baş AY, Demirel N, Zenciroglu A, Göl N, Tanir G. Nosocomial blood stream infections in a neonatal intensive care unit in
Ankara, Turkey. Turk J Pediatr. 2010 Sep-Oct;52(5):464-70.
• Staphylococcus aureus (18.5%), Acinectobacter
baumannii (16.3%), Klebsiella pneumoniae (11.9%),
Escherichia coli (9.6%), and Pseudomonas aeruginosa
(8.1%). Tseng YC, Chiu YC, Wang JH, Lin HC, Lin HC, Su BH, Chiu HH. Nosocomial bloodstream infection in
a neonatal intensive care unit of a medical center: a three-year review. J Microbiol Immunol Infect. 2002
Sep;35(3):168-72.
69. • Acinetobacter spp. (47.9%), Pseudomonas spp,
(23.6%), Klebsiella/Enterobacter spp. (8.3%),
Coagulase-negative staphylococci (8.3%) and
Staphylococcus aureus (6.3%) Markovid-Denid L, Durisid J, Nikolid T, Ramadani R, Ilid
S, Stevanovid S. Causative agents of neonatal nosocomial infections and their resistance to antibioticsMed Pregl. 2006
Mar-Apr;59(3-4):155-9.
70. Ventillator associated pneumonia
• Pseudomonas aeruginosa, Klebsiella
pneumoniae and Acinetobacter spp
predominant. (Witaya Petdachai in 2004)
71. Catheter-related bloodstream
infection
• Gram-positive cocci, which are responsible for at
least two-thirds of infections
• De Brito et al : coagulase-
negative Staphylococci (CoNS) the most common
and S. aureus the second leading cause
74. • Prophylactic antibiotics
• They are given to prevent infection.
• Not indicated in almost all situations in
neonatology.
• High level evidence: not useful for the prevention
of infection following umbilical vessel or central
venous catheterisation
• Antibiotics for all infants receiving mechanical
ventilation not supported by evidence from
randomised controlled trials.
75. • The only prophylactic use of antimicrobials: fungal
prophylaxis in preterm infants on broad spectrum
antibiotics or with central arterial or venous lines.
• A Cochrane systematic review: antifungals reduce the
incidence of systemic fungal infections.
• To date there is no evidence that use of oral
prophylactic antifungal agents has changed the
susceptibility of infecting organisms.
76. Prophylactic
antifungal agents
• The antifungal prophylaxis guideline (Royal Maternity
Hospital, Belfast)
• VLBW baby should be considered for antifungal
prophylaxis if :
• under treatment with a third generation cephalosporin
• under treatment for more than 10 consecutive days with
a systemic broad spectrum antibiotic
• fungal colonisation from surface sites and a central
venous catheter in situ.
77. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth
weight infants. Austin N, McGuire W. Cochrane Database Syst Rev. 2013
• 11 eligible trials enrolling a total of 1136 infants
• Seven trials (involving 880 infants) compared
systemic antifungal prophylaxis versus placebo or no
drug
• Statistically significant reduction in the incidence of
invasive fungal infection in infants
• Meta-analysis did not find a statistically significant
difference in the risk of death prior to hospital
discharge
• Very limited data on long-term neurodevelopmental
outcomes were available.
78. Prophylactic oral antifungal agents to prevent systemic candida infection in preterm infants.
Austin N, McGuire W. Cochrane Database Syst Rev. 2004
• 3 eligible trials
• Nystatin with no treatment (67 infants)
• Miconazole with placebo (600 infants)
• Nystatin with fluconazole (21 infants).
79. • Nystatin versus no treatment, systemic fungal
infection was significantly reduced
• Miconazole with placebo: no significant effect
• Neither study found a significant effect on mortality,
• No significant difference in the mean number of days
infants received ventilation or stayed in the neonatal
intensive care unit.
• Oral fluconazole with nystatin, no significant
difference in systemic fungal infection or mortality
was reported.
80. Selective fluconazole prophylaxis in high‐risk babies to reduce invasive fungal
infection
Brian A McCrossan, Elaine McHenry, Fiona O'Neill, Grace Ong, and David G Sweet
Arch Dis Child Fetal Neonatal Ed
v.92(6); Nov 2007
• Fluconazole 6 mg/kg for 3 weeks. Dose interval
every 72 h during the first 2 weeks of life.
Thereafter, dose interval reduced to every 48 h until
3 weeks old when daily fluconazole is given.
• 6/33 babies eligible for prophylaxis developed
culture proven Candida sepsis before compared with
no (0/31) babies after the guideline was
implemented (p=0.03).
• Selective antifungal prophylaxis has reduced invasive
fungal sepsis
81. References
• Choice and Duration of Antimicrobial Therapy for Neonatal
Sepsis and Meningitis International Journal of Pediatrics
Volume 2011 (2011)
• Cochrane Database Syst Rev. 2013
• Prolonged Initial Empirical Antibiotic Treatment is
Associated with Adverse Outcomes in Premature Infants J
Pediatr. 2011 November ; 159(5): 720–725.
• Choosing the right empirical antibiotics for neonates Arch
Dis Child Fetal Neonatal Ed. 2011 January ; 96(1): F2–F3.
• Rationing antibiotic use in neonatal units Arch Dis Child
Fetal Neonatal Ed 2000;82:F1–F2
• Antibiotic Use and Misuse in the Neonatal Intensive Care
Unit Clin Perinatol. 2012 March ; 39(1): 61–68.