424
LETTERS to the EDITOR
Prophylactic vancomycin to prevent staphylococcal septicaemia in very-low-birth-weight infants SiR,—Coagulase-negative staphylococci (CONS) are the most important cause of infection acquired in neonatal intensive care units and 20-40% of all premature infants below 1500 g acquire CONS septicaemia.1,2 Not being associated with a high mortality, these infections contribute importantly to long hospital stays and high treatment costs.2 Prophylactic antibiotics in very-low-birth weight (VLBW) infants have been studied, without success.3 We have studied the prophylactic use of vancomycin in a low-dose regimen of 5 mg/kg infused over 1 h twice daily. All VLBW infants were randomly assigned to a treatment or a control group. Nurses and house-officers were "blinded": the consultantin-charge was aware of the randomisation. In all cases antibiotic treatment for early-onset septicaemia had been completed or the babies were at least 4 days old. The study was approved by our institution’s human research committee and consent from parents was obtained. We monitored patients for CONS septicaemia, defined as a clinical episode of shock, apnoeas, and feeding difficulties, together with laboratory signs (C-reactive protein, polymorphonuclear elastase, abnormal differential white-bloodcell count, positive blood culture). Vancomycin was continued, provided no episode suggestive of septicaemia was observed, until parenteral nutrition or medication was no longer needed; in the controls the observation period was similarly defined. After 20 patients had been studied in each group an interim analysis revealed a significantly lower rate of CONS septicaemia in the treatment group (p < 0024, Fisher’s exact test):
After the interim analysis we treated all VLBW infants with vancomycin. Tracheal and pharyngeal aspirates have not revealed the emergence of vancomycin-resistant organisms since, in a total of
40 infants. shown to be effective in and in cancer patients with tunnelled central venous catheters.4,5 The adverse reactions reported (red-man syndrome, cardiac depression, hypotension) were not found with our low-dose vancomycin regimen. Surprisingly vancomycin prophylaxis did not reduce the frequency of tracheal CONS contamination but it did affect septicaemia. Vancomycin resistance has not emerged with this protocol and warnings against prophylactic vancomycin6 may not be valid for low doses. In circumstances where other gram-positive organisms (enterococci or Staphylococcus aureus) are important our view might be different. Vancomycin seems to be an effective agent against CONS, with less risk of resistance developing than, for example,
Prophylactic vancomycin was neurosurgical patients with shunts
with teicoplanin.’ We thank Prof R. Marre, Institute for Medical Microbiology, Medical University of Liibeck, for evaluating bacterial cultures.
Group Treated (n = 20) Controls
(n=21)
positive
CONS
Other
0 6
2 4
CONS
Other 45 53
We obtained tracheal or deep pharyngeal cultures on day 3 in all patients. We measured serum creatinine and vancomycin peak and trough levels on day 3 and compared the cumulative doses of vancomycin in the prophylactic treatment group and in the controls (in whom any septic episodes were treated with a usual daily dosage of 15-20 mg/kg vancomycin) and length of hospital stay. Groups were compared by Mann-Whitney U test: Treated (n = 20) 1162(+196) Birthweight (g) Gestation age (wk) 29-9 (+ 1 -8) 8-2 (-17) 5 min apgar Days antibiotic therapy for early onset —
infections Days of vancomycin observation
7-5 (+ 5)
11’7 (-4.9) 86 ( - 45) Cumulative dose (mg)t 114.6(61) Vancomycin trough Days in hospital
(ltg/1) Vancomycin peak (lrg/1)
Controls (n=21) 1190 ( - 208) 29-7 (+ 2-0) 8-0 (-1-3) 6-4 (+ 1 9) 7.2
(-3-1)*
73 (29) 98 (+82)
5-12 (2 3) 16-0(8-1)
..
..
*Treated, days of vancomycin therapy, controls, observation days until intravenous access or septicaemia (p < 0 001 ) tCumulatlve dose prophylactically or, m septicaemia Data are mean (SD)
controls,
for
suspected
Only the observation period was significantly different and we attribute that to the higher rate of septic episodes in the controls.
GERALD NACHTRODT ANDREAS RICHTER FRIEDRICH K. TEGTMEYER
A, Senders RC, Visser MR, et al. Septicemia due to coagulase negative staphylococci in a neonatal intensive care unit: clinical and bacteriological features and contaminated fluids as a source of sepsis. Pediatr Infect Dis 1983; 2: 426-31 Freeman J, Epstein MF, Smith NE, Platt R, Sidebottom DG, Goldmann DA. Extra hospital stay and antibiotic usage with nosocomial coagulase negative staphylococcal bacteremia m two neonatal intensive care populations. Am J Dis Child 1990; 144: 324-29. Bard H, Albert G, Teasdale F, Doray E, Martineau B Prophylactic antibiotics in chronic umbilical artery catheterization in respiratory distress. Arch Dis Child 1973,
1. Fleer
2.
Tracheal aspirate
Septicaemia
JENS C. MÖLLER
Paediatric Clinic, Medical School, University of Lubeck, D-2400 Lubeck, Germany
3.
48: 630-36. C, Mohs E, Sklar FH, Nelson JD, McCracken GH. Adverse reactions to vancomycin used as prophylaxis for CSF shunt procedures. Am J Dis Child 1984, 138: 17-19. 5. Schwartz C, Henrickson KJ, Roghman K, Powell K. Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin susceptible organisms. J Clin Oncol 1990; 8: 1591-97 6. Schwalbe RS, Stapleton JT, Gilligan PH. Emergence of vancomycin resistance in coagulase negative staphylococci. N Engl J Med 1987; 316: 927-31 7. Watanakunakorn C In-vitro selection of resistance of staphylococcus aureus to teicoplanin and vancomycin. J Antimicrob Chemother 1990; 25: 69-72
4. Odio
Inhalation
injury with a
new
device in
child
a
infant safety
SiR,—Reports of deliberate adulteration of commercially manufactured baby-food began in March, 1989 (Times, March 17). Genuine cases were rare, but the resulting anxiety led manufacturers to develop plastic anti-tamper oversleeves for jars as a precaution. These sleeves may be transparent to allow the label and contents to be viewed, with a tear-down strip for access. We report inhalational injury in an infant due to such a tear-down strip. A 14-month-old infant choked and became cyanosed while being fed commercially manufactured baby-food. After a backslap and some improvement in his condition, he was taken to the local hospital where an inhaled foreign body was suspected. An otorhinolaryngologist did a bronchoscopy and food was removed from the trachea, but no other foreign body was found. He received antibiotics and was discharged.
LETTERS to the EDITOR
Prophylactic vancomycin to prevent staphylococcal septicaemia in very-low-birth-weight infants SiR,—Coagulase-negative staphylococci (CONS) are the most important cause of infection acquired in neonatal intensive care units and 20-40% of all premature infants below 1500 g acquire CONS septicaemia.1,2 Not being associated with a high mortality, these infections contribute importantly to long hospital stays and high treatment costs.2 Prophylactic antibiotics in very-low-birth weight (VLBW) infants have been studied, without success.3 We have studied the prophylactic use of vancomycin in a low-dose regimen of 5 mg/kg infused over 1 h twice daily. All VLBW infants were randomly assigned to a treatment or a control group. Nurses and house-officers were "blinded": the consultantin-charge was aware of the randomisation. In all cases antibiotic treatment for early-onset septicaemia had been completed or the babies were at least 4 days old. The study was approved by our institution’s human research committee and consent from parents was obtained. We monitored patients for CONS septicaemia, defined as a clinical episode of shock, apnoeas, and feeding difficulties, together with laboratory signs (C-reactive protein, polymorphonuclear elastase, abnormal differential white-bloodcell count, positive blood culture). Vancomycin was continued, provided no episode suggestive of septicaemia was observed, until parenteral nutrition or medication was no longer needed; in the controls the observation period was similarly defined. After 20 patients had been studied in each group an interim analysis revealed a significantly lower rate of CONS septicaemia in the treatment group (p < 0024, Fisher’s exact test):
After the interim analysis we treated all VLBW infants with vancomycin. Tracheal and pharyngeal aspirates have not revealed the emergence of vancomycin-resistant organisms since, in a total of
40 infants. shown to be effective in and in cancer patients with tunnelled central venous catheters.4,5 The adverse reactions reported (red-man syndrome, cardiac depression, hypotension) were not found with our low-dose vancomycin regimen. Surprisingly vancomycin prophylaxis did not reduce the frequency of tracheal CONS contamination but it did affect septicaemia. Vancomycin resistance has not emerged with this protocol and warnings against prophylactic vancomycin6 may not be valid for low doses. In circumstances where other gram-positive organisms (enterococci or Staphylococcus aureus) are important our view might be different. Vancomycin seems to be an effective agent against CONS, with less risk of resistance developing than, for example,
Prophylactic vancomycin was neurosurgical patients with shunts
with teicoplanin.’ We thank Prof R. Marre, Institute for Medical Microbiology, Medical University of Liibeck, for evaluating bacterial cultures.
Group Treated (n = 20) Controls
(n=21)
positive
CONS
Other
0 6
2 4
CONS
Other 45 53
We obtained tracheal or deep pharyngeal cultures on day 3 in all patients. We measured serum creatinine and vancomycin peak and trough levels on day 3 and compared the cumulative doses of vancomycin in the prophylactic treatment group and in the controls (in whom any septic episodes were treated with a usual daily dosage of 15-20 mg/kg vancomycin) and length of hospital stay. Groups were compared by Mann-Whitney U test: Treated (n = 20) 1162(+196) Birthweight (g) Gestation age (wk) 29-9 (+ 1 -8) 8-2 (-17) 5 min apgar Days antibiotic therapy for early onset —
infections Days of vancomycin observation
7-5 (+ 5)
11’7 (-4.9) 86 ( - 45) Cumulative dose (mg)t 114.6(61) Vancomycin trough Days in hospital
(ltg/1) Vancomycin peak (lrg/1)
Controls (n=21) 1190 ( - 208) 29-7 (+ 2-0) 8-0 (-1-3) 6-4 (+ 1 9) 7.2
(-3-1)*
73 (29) 98 (+82)
5-12 (2 3) 16-0(8-1)
..
..
*Treated, days of vancomycin therapy, controls, observation days until intravenous access or septicaemia (p < 0 001 ) tCumulatlve dose prophylactically or, m septicaemia Data are mean (SD)
controls,
for
suspected
Only the observation period was significantly different and we attribute that to the higher rate of septic episodes in the controls.
GERALD NACHTRODT ANDREAS RICHTER FRIEDRICH K. TEGTMEYER
A, Senders RC, Visser MR, et al. Septicemia due to coagulase negative staphylococci in a neonatal intensive care unit: clinical and bacteriological features and contaminated fluids as a source of sepsis. Pediatr Infect Dis 1983; 2: 426-31 Freeman J, Epstein MF, Smith NE, Platt R, Sidebottom DG, Goldmann DA. Extra hospital stay and antibiotic usage with nosocomial coagulase negative staphylococcal bacteremia m two neonatal intensive care populations. Am J Dis Child 1990; 144: 324-29. Bard H, Albert G, Teasdale F, Doray E, Martineau B Prophylactic antibiotics in chronic umbilical artery catheterization in respiratory distress. Arch Dis Child 1973,
1. Fleer
2.
Tracheal aspirate
Septicaemia
JENS C. MÖLLER
Paediatric Clinic, Medical School, University of Lubeck, D-2400 Lubeck, Germany
3.
48: 630-36. C, Mohs E, Sklar FH, Nelson JD, McCracken GH. Adverse reactions to vancomycin used as prophylaxis for CSF shunt procedures. Am J Dis Child 1984, 138: 17-19. 5. Schwartz C, Henrickson KJ, Roghman K, Powell K. Prevention of bacteremia attributed to luminal colonization of tunneled central venous catheters with vancomycin susceptible organisms. J Clin Oncol 1990; 8: 1591-97 6. Schwalbe RS, Stapleton JT, Gilligan PH. Emergence of vancomycin resistance in coagulase negative staphylococci. N Engl J Med 1987; 316: 927-31 7. Watanakunakorn C In-vitro selection of resistance of staphylococcus aureus to teicoplanin and vancomycin. J Antimicrob Chemother 1990; 25: 69-72
4. Odio
Inhalation
injury with a
new
device in
child
a
infant safety
SiR,—Reports of deliberate adulteration of commercially manufactured baby-food began in March, 1989 (Times, March 17). Genuine cases were rare, but the resulting anxiety led manufacturers to develop plastic anti-tamper oversleeves for jars as a precaution. These sleeves may be transparent to allow the label and contents to be viewed, with a tear-down strip for access. We report inhalational injury in an infant due to such a tear-down strip. A 14-month-old infant choked and became cyanosed while being fed commercially manufactured baby-food. After a backslap and some improvement in his condition, he was taken to the local hospital where an inhaled foreign body was suspected. An otorhinolaryngologist did a bronchoscopy and food was removed from the trachea, but no other foreign body was found. He received antibiotics and was discharged.
