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The objective of this study was to investigate the association between systolic, diastolic, and mean blood pressures (SBP, DBP, and MBP) and adverse outcomes in preterm neonates with late-onset sepsis (LOS).This is a two-center retrospective study over 6 years. Neonates35 weeks gestational age (GA) with blood ± cerebrospinal fluid culture positive for organisms other than coagulase-negative Staphylococcus at72 h age were included. Outcome measures were organ dysfunction (ODF) using the predefined criteria and post-ODF mortality (≤7 days from LOS onset). The lowest noninvasive blood pressures (BPs) recorded at baseline (24-48 h pre-LOS) and 0-12, 13-24, 25-36, and 37-48 h post LOS were analyzed.Of 147 neonates, ODF occurred in 70 (48%), of which 20 (29%) died. ODF was associated with a drop in all BP components, starting 0-12 h post-LOS onset (p 0.01 for all); BPs remained unchanged in the non-ODF group. Mortality was associated with a greater reduction in SBP [-13 (-19, -8) vs. -4 (-8, 0); p 0.01] and MBP [-9 (-13, -5) vs. +1 (-1, +4); p = 0.03] 0-12 h post-LOS onset. SBP had a higher area under the curve for mortality than MBP and DBP (0.83, 0.81, and 0.78, respectively). An inverse relation may exist between corrected GA and percentage reduction in SBP from baseline for equivalent risk of death.Reduction in BPs early in illness may identify preterm neonates at the highest risk of ODF and mortality from LOS.Drop in BPs from baseline starting in the immediate post-illness onset period may identify preterm neonates at the highest risk of developing ODF and mortality in LOS. Lowest systolic followed by mean BP measured during the first 12 h of illness provided the highest discriminating ability for LOS-related mortality. Absolute BPs recorded during the first 12 h of illness performed better than relative change from baseline for identifying neonates at risk of LOS-related mortality. The specific BP thresholds identified in this study may inform future therapeutic trials.

La prise en charge de la persistance du canal artériel est l’un des aspects les plus litigieux des soins aux nouveau-nés prématurés. On peut la classer en deux grandes catégories : la prophylaxie et le traitement en cas de symptômes. L’administration prophylactique d’indométacine par voie intraveineuse chez les nouveau-nés d’extrême petit poids à la naissance peut limiter les graves hémorragies intraventriculaires. L’échocardiographie est systématiquement recommandée pour confirmer une persistance du canal artériel avant d’envisager le traitement en cas de symptômes, qui peut prendre la forme d’un traitement conservateur, d’une pharmacothérapie ou d’une fermeture invasive. L’ibuprofène doit être considéré comme le traitement pharmacologique de première intention dans cette situation. Une forte dose peut être à privilégier, particulièrement chez les nouveau-nés prématurés de plus de trois à cinq jours de vie. Si deux traitements pharmacologiques consécutifs échouent ou si la pharmacothérapie est contre-indiquée, on peut envisager une fermeture invasive en cas de symptômes marqués lorsque l’échocardiographie révèle des signes de shunt à fort volume à travers le canal artériel et de circulation pulmonaire excessive.

Background: Previous studies in adults have refuted the use of nitrites as a predictor of bacterial resistance to both trimethoprim-sulfamethoxazole and cephalosporins. Some centers now consider first-line outpatient therapy with an oral third-generation cephalosporin appropriate for young children. Objective: The objective of this study was to determine if nitrite-negative pediatric urinary tract infections (UTIs) were more likely than nitrite-positive UTIs to be resistant to cephalosporins. This may enable physicians to adjust antimicrobial therapy before patients leave the Emergency Department (ED) to avoid the complications of ineffectively treated pediatric UTIs. Methods: A retrospective chart review examined, over a 9-month period, 173 pediatric patients who were diagnosed with a clinical UTI in the ED and who also had a positive urine culture and a recorded dipstick at the time of visit. The chi-squared test and Fisher's exact test were used to compare nitrite-negative vs. nitrite-positive UTIs for resistance to third-generation cephalosporins and other empiric antimicrobials. Results: For third-generation cephalosporins, 1.4% of nitrite-positive UTIs were resistant, whereas 14.4% of nitrite-negative UTIs were resistant (95% confidence interval [CI] −0.22 to −0.05). For first-generation cephalosporins, 8.4% were resistant in the nitrite-positive group, compared to 22.2% in the nitrite-negative group (95% CI −0.24 to −0.03). Conclusion: The absence of urinary nitrites is a significant indicator for potential resistance to cephalosporins in pediatric UTIs. Due to low levels of pediatric UTI resistance, cephalosporins continue to represent useful empiric therapy in the general pediatric population. However, in high-risk patients, physicians may opt to alter their empiric choice of antibiotic based on the presence of urinary nitrites.

Afive-month-old term male infant was referred by his family doctor for evaluation of a vesicular rash. The mother first noticed several clusters of vesicles on the baby’s chest five days before presentation. In the subsequent four days, new adjacent vesicles erupted on the chest with clear discharge. He had slightly decreased appetite but normal voiding and stools, with no accompanying fever. A review of the infant’s systems was otherwise unremarkable. The baby was born to a 32-year-old Pakistani-Canadian woman who remained in Pakistan during her pregnancy. Antenatal screening for HIV, hepatitis B and syphilis was negative, and a rubella immunoglobulin G test was positive. The baby was born at 39 weeks’ gestational age by spontaneous vaginal delivery with no perinatal complications. The birth weight was 3.2 kg and the baby was discharged home on the second day of life with a normal physical examination. He had received his two- and four-month routine immunizations uneventfully. There was no family history of immunodeficiency or recurrent infections. A physical examination revealed a thriving, afebrile and well-appearing infant. Multiple crops of vesicles on an erythematous base were present on both the anterior and posterior right hemithorax (Figure 1). There were no satellite lesions. One further detail on history suggested the diagnosis. Case 2: Making a diagnosis: Lest we forget the family A n 11-year-old girl was referred to the paediatric gastroenterology service with symptoms of hoarse voice, central chest discomfort with a frequent acidic taste in the mouth, and mild epigastric pain. An assessment by an otolaryngologist revealed congestion and small nodules on her vocal cords. A diagnosis of gastroesophageal reflux disease (GERD) had been entertained. The patient was otherwise well without any vomiting, dysphagia, alteration in stool pattern or weight loss. Her history was unremarkable, with normal growth and development. During history taking in the outpatient clinic, it was inquired as to whether anyone else in the family had similar problems. The mother reported that her husband had severe, chronic GERD requiring a fundoplication. The physical examination of the patient was normal. She was prescribed ranitidine and a follow-up was arranged. When the patient was seen two months later, there was little improvement in her symptoms. A trial of omeprazole was initiated. A lack of response led to an increase in the dose of the medication, but that was also of no avail. An upper gastrointestinal endoscopy was performed to look for reflux esophagitis or eosinophilic esophagitis. On endoscopy, the esophagus and stomach appeared normal. Inspection of the duodenum revealed the unexpected diagnosis. CliniCian’s Corner