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What you need to know Introducing routine testing for group B streptococcus (GBS) for all women in late pregnancy would likely reduce cases of early onset infection in their newborns, but might also increase the number of women given antibiotics during labour. One in five pregnant women carries GBS in the gut or genital tract, and more than half of them will pass it to their child during pregnancy, labour (most commonly), or after birth.1 Most babies exposed to maternal GBS remain well, but one in 1750 newborns in the UK and Republic of Ireland develops early onset GBS infection, mostly pneumonia and sepsis. Each year in the UK about 40 babies die from GBS infection, and one in 14 of the survivors has a long term disability.1 Babies born preterm are at higher risk of serious infection and death.2 Low quality evidence shows …

AimTo ensure neonates in transitional care and postnatal wards are receiving antibiotics appropriately. NICE CG1491 advises to consider stopping antibiotics at 36 hours in babies given antibiotics because of risk factors for infection or clinical indicators of possible infection where:the blood culture is negative,the levels and trends of C-reactive protein (crp) concentration are reassuring andno clinical indicators of possible infectionNeonatal unit was excluded from this study; since daily clinician led ward rounds to review antibiotics already occur. Antibiotics not reviewed in the 36 hour time frame were due to delays in receiving the second crp level. Daily ward rounds to review antibiotics in neonates were not happening on transitional care and postnatal wards, thus to ensure regular care, advanced neonatal nurse practitioner led reviews were implemented.MethodA crp sample should be taken after delivery and in babies given antibiotics because of possible infection, the crp concentration is measured again 18–24 hours after presentation. The role of the ANNP is to ensure both crp levels are checked and the blood culture is negative, with the aim of stopping antibiotics at 36 hours before the second dose of gentamicin is due. In summary neonates that do not need antibiotics should have only had approximately 3 doses of benzylpenicillin and 1 dose of gentamicin. Audits were carried out on neonates in transitional care and postnatal wards who were receiving antibiotics. The initial base line audit was done over 3 months to assess if antibiotics were reviewed in 36 hours. This was deduced by a signature from the ANNP either stating on the drug chart that antibiotics would continue for 5 days until crp has decreased or the antibiotic would be discontinued if the crp was low. This audit was repeated a year later.ResultsDuring the first 3 months audit the proportion of babies having their antibiotics reviewed within 36 hour time frame rose from 3% in month 1 to 25% and 50% in months 2 and 3 consecutively. During the second 3 month audit, the proportion of babies having their antibiotics reviewed was 78% in month 1 and 80% in the following two months. The first audit showed a rapid improvement, whereas the second audit showed an significant improvement compared to the end of the first audit, which was sustained throughout the full three months.ConclusionThe ANNP was a simple and no cost solution in ensuring antibiotic stewardship was consistent throughout neonates, reducing the length of stay of neonates and their mothers. The 20% of babies who are still not having a 36 hour review may be because of delays in blood cultures reaching the laboratories to commence incubation.ReferenceNeonatal infection (early onset): antibiotics for prevention and treatment. NICE CCG149 2012.

Objective: To establish incidence rates, clinic referrals, hospitalisations, mortality rates and baseline determinants of morbidity among infants in an Indian slum. Design: A community-based birth cohort with twice-weekly surveillance. Setting: Vellore, South India. Subjects: 452 newborns recruited over 18 months, followed through infancy. Main outcome measures: Incidence rates of gastrointestinal illness, respiratory illness, undifferentiated fever, other infections and non-infectious morbidity; rates of community-based diagnoses, clinic visits and hospitalisation; and rate ratios of baseline factors for morbidity. Results: Infants experienced 12 episodes (95% confidence interval (CI) 11 to 13) of illness, spending about one fifth of their infancy with an illness. Respiratory and gastrointestinal symptoms were most common with incidence rates (95% CI) of 7.4 (6.9 to 7.9) and 3.6 (3.3 to 3.9) episodes per child-year. Factors independently associated with a higher incidence of respiratory and gastrointestinal illness were age (3-5 months), male sex, cold/wet season and household involved in beedi work. The rate (95% CI) of hospitalisation, mainly for respiratory and gastrointestinal illness, was 0.28 (0.22 to 0.35) per child-year. Conclusions: The morbidity burden due to respiratory and gastrointestinal illness is high in a South Indian urban slum, with children ill for approximately one fifth of infancy, mainly with respiratory and gastrointestinal illnesses. The risk factors identified were younger age, male sex, cold/wet season and household involvement in beedi work.

Background and Aims Central venous catheter-associated bloodstream infection (CBSI) is a serious complication in home parenteral nutrition (HPN) patients. Prevention of CBSI in hospitals is well-established, but in the home environment presents additional challenges. We applied hazard analysis and critical control points principles to develop a systematic approach to preventing HPN-related CBSI. Here we describe the corrective actions and their clinical impact. Methods Factors predisposing to infection, and corrective actions were identified through consensus by a multidisciplinary group of healthcare professionals between April and June 2012. The impact of these actions on CBSI was observed. Results Key corrective actions were: Staphylococcus aureus nasal screening and decolonisation where appropriate. Multidisciplinary discharge planning meetings included consideration of patients’ microbiology histories and optimisation of treatment of comorbidities (e.g. atopic eczema). Increased monitoring of line access and care practices at home, aiming to attain the same standards as in hospital. Launch of updated illustrated guide to identification and management of line site problems. Streamlining of microbiology result reporting to facilitate early treatment of local infections. Taurolidine locks for one patient with a poor line infection history. Between April 2011 and March 2012 there were 13 CBSI acquired outside hospital, and during planning and implementation of corrective actions (April–June 2012) there were 4 CBSI. By contrast there was only one CBSI during the in the nine months following full implementation. Conclusion A multidisciplinary approach to the ongoing management of HPN patients can dramatically reduce their risk of CBSI.

We present a case of a 24-year-old man who suffered acute shoulder pain and subsequent inability to move his arm while lifting weights in the bench-press position. He attended A&E where he was examined and X-rays were performed. He was diagnosed with presumed pectoralis major tendon rupture and was discharged to fracture clinic the following day with analgesia. On review in clinic he was found to have a posterior shoulder dislocation and was taken to theatre for relocation under anaesthesia. This case report examines the mechanism, investigations and management of posterior shoulder dislocation.

The accuracies of chromogenic agar and the GeneXpert real-time PCR system (Cepheid, Sunnyvale, California, USA) for admission methicillin-resistant Staphylococcus aureus (MRSA) screening of 1336 consecutive paediatric intensive care unit patients (1282 evaluable swab results) were determined using enrichment culture as the reference standard. Twenty (1.6%) swabs were MRSA-positive by enrichment culture (reference test). PCR was more sensitive (0.9, 95% CI 0.68 to 0.99 vs 0.65, 95% CI 0.41 to 0.85) but less specific (0.98, 95% CI 0.98 to 0.99 vs 100%) than chromogenic agar. After introduction of screening no patient developed MRSA infection or acquired MRSA after admission. In the preceding 3 years of screening, 16 patients had MRSA diagnosed after admission, nine presenting with infection. The accuracy of PCR was comparable to previous studies, but the positive predictive value in a low prevalence paediatric population was only 0.49. Screening provided some clinical benefits, to which the early availability of PCR results may have contributed.

Background and Aims Gram-negative bacteria present an increasing threat to NICU babies. Because the gastrointestinal tract is the primary colonisation site, we added rectal swabbing to routine admission and weekly screening of babies from September 2010. We consider here the impact of this strategy on clinical and infection control management. Methods Rectal swabs were cultured for the following Gram-negative bacteria of interest (GNBi): Serratia; gentamicin-resistant &/or ESBL-producing Enterobacteriaceae; Pseudomonas aerugionsa (PA). Colonised babies were isolated, but were not treated with antibiotics unless clinically indicated. Results GNBi (except PA) were isolated from 55 (2.6%) of 2101 admissions, September 2010–March 2012: 21 gentamicin-resistant Enterobacteriaceae; 9 ESBL-producing Enterobacteriaceae; 25 Serratia. 45 of the GNBi were detected in rectal swabs: in 38 (64.7%) rectal swabs were the first, and in 28 (33.3%) the only, culture-positive samples. Only one baby had GNBi infection (bacteraemia on the same day as a positive rectal swab). There were 13 instances of 2–3 babies having the same bacterium within 7 days of each other. In one case, seven babies were found with Serratia over 7 days. PA results are not shown for the first 7 months, because of an exceptional event causing PA colonisation then. After April 2011 there were 5 cases (4 detected on rectal swabs: the only positive site in 3): there was no clustering of these cases. Conclusion An unexpectedly high proportion of NICU babies had GNBi. The high frequency of patient-to-patient transmission suggests that rectal screening can be an important tool in controlling these bacteria.

Gram-negative antibiotic resistance is currently of major concern worldwide. In the UK, the prevalence of multi-resistant gram-negative bacteria (MRGNB) is increasing,1 and outbreaks have occurred in neonatal units (NNUs). Up to 12% of neonates undergo a septic screen at birth, and most of them receive empiric antibiotics.2 Around 70% of NNUs use narrow-spectrum penicillin/gentamicin combinations for empiric treatment of neonatal sepsis.3 However, these regimens may not be active against MRGNB. Vergnano et al 4 found that Enterobacteriaceae accounted for around 20% to 35% of early- and late-onset sepsis, respectively, underlining the threat that MRGNB pose in neonatology. Unlike many other …