PIDSP Journal, 2005 Vol. 9 No. 2 PIDSP JOURNAL

PIDSP Journal, 2005 Vol. 9 No. 2Copyright © 2005

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ORIGINAL STUDIESStudy of bacterial flora in the initial oropharyngeal aspirate and

blood of potentially septic neonates

Pauline Alonday-Pugay, MD, Anna Lisa Ong-Lim, MD...................1

Retrospective analysis of the clinical profile and immediate outcome

of pediatric patients aged three months to 17 years, diagnosed with

pleural effusion or empyema thoracis, admitted to a tertiary

government hospital during january 1998 to december 2000

Dexter D. Cheng, MD, Alexander O. Tuazon, MD.........................6

A randomized placebo-controlled trial on the use of probiotics in

the prevention of nosocomial infection in pediatric patients with

hematologic and oncologic diseases

Arlene Grace L. Simon, MD, Jossie Rogacion, MD.......................10

A five-year retrospective study on the common microbial isolates

and sensitivity pattern on blood culture of pediatric cancer patients

admitted at the philippine general hospital for febrile neutropenia

Ailyn T. Isais-Agdeppa, MD, Lulu Bravo, MD................................17

Clinical correlation of neonatal and maternal hematological

parameters as predictors of neonatal sepsis

Willa Antoniette B. Mayuga, MD, Pura Flor D. Isleta, MD............21

Serum concentration of pyrazinamide suspension in children with

tuberculosis: A therapeutic drug monitoring

Daisy O. Sanchez, MD, Cecilia C. Maramba-Untalan, MD*..........42

The analysis of clinical and social profile of congenital rubella

syndrome seen among up-pgh patients from the years 1993 -

2002 (a 10 year prevalence review)

Coralee Lianko Agnas , MD.........................................................49

PIDSP JOURNAL

Vol. 9 No. 2

July - December 2005

PEDIATRIC INFECTIOUSDISEASE SOCIETY OF

THE PHILIPPINES

*Department of Pediatrics, UP-PGH

Keywords: oropharyngeal aspirate, blood culture, potentially septic neonates

STUDY OF BACTERIAL FLORA IN THE INITIAL OROPHARYNGEAL

ASPIRATE AND BLOOD OF POTENTIALLY SEPTIC NEONATES

Pauline Alonday-Pugay, MD*, Anna Lisa Ong-Lim, MD*

ABSTRACT

There are a considerable number of admissions

of neonates because of vertical transmission of infec-

tion. The sterility of amniotic fluid is questionable in cases

of premature rupture of membrane (PROM), spontane-

ous preterm labor, and infection. A Prospective Risk

Analytical Study was conducted to evaluate the use of

oropharyngeal aspirate in the diagnosis of sepsis in po-

tentially septic neonates born at OB Admitting Section,

Philippine General Hospital from March to August 2004.

Included were 107 neonates, of these, 15 (14.02%) have

maternal risk factor of PROM; 34 (31.78%) have ma-

ternal risk factor of spontaneous preterm labor alone; 38

(35.51%) have maternal risk factor of UTI; 15 (14.02%)

have maternal risk factor of respiratory tract infection;

and 2 (4.6%) have maternal risk factor of fever alone.

Immediately after birth, fluid from the oropharyngeal are

and blood was sent for culture. The neonates were fol-

lowed up within 72 hours, and it was noted that 50

(46.73%) developed jaundice, 17 (15.89%) had pneu-

monia, 7 (6.54%) had necrotizing enterocolitis (stage IA

to IV) and 3 (2.80%) had decreased activity, tempera-

ture instability and hypoglycemia, collectively grouped

under sepsis. Of the 107 subjects, 33.6% have oropha-

ryngeal aspirate growth and 8.4% have blood culture

growth. Among the subjects who have oropharyngeal

aspirate growth, 25% have a concomitant blood CS

growth, irregardless of the organism isolated. Of the

subjects who had growth on their blood culture, 77%

have the same organism isolated in their oropharyngeal

aspirate. PROM and UTI highly correlated with posi-

tive growth in the oropharyngeal aspirate. Acinetobacter

baumanii and Alkaligenes faecalis isolated from

oropharyngeal aspirate has 100% correlation with blood

culture and E. coli isolated from the oropharyngeal aspi-

rate correlated 83.33% with blood culture. The sensitiv-

ity of oropharyngeal aspirate culture growth irregardless

of the organism isolated is 100% and the specificity is

75%. In conclusion, oropharyngeal aspirate when posi-

tive for growth may not reflect growth in blood culture,

and when negative for growth highly correlates with a

blood culture that has no growth.

INTRODUCTION

One of the biggest goals of doctors in every

institution is to decrease the incidence of neonatal

septicemia. In the PGH alone, the statistics points

unfavorably to the high number of neonatal deaths due to

infection. Early detection by surveillance is a must to

eliminate high mortality rates caused by infection.

Neonatal mortality due to neonatal infection

brought about by maternal infection is being faced hand

in hand by pediatricians and obstetricians. Subclinical

ascending infections through the lower female genital tract

are predominant worldwide. The importance of prenatal

check-up has been emphasized, as well as proper

hygiene. But still, there are a considerable number of

admissions of neonates in the Neonatal Intensive Care

Unit because of vertical transmission of infection. Usual

source of bacterial infection are the colonizers. The

bacteria load may increase and thus, may predispose the

immunologically immature newborn to sepsis. The overall

mortality rate of neonates with congenital neonatal sepsis

ranges between 25 to 90%.

The amniotic fluid is normally sterile, but its

sterility is questionable in cases of premature rupture of

membrane, spontaneous preterm labor, and infection,

especially genitourinary infection and respiratory tract

infection.

Preterm labor occurs in 20% of pregnancies in

low-income countries whereas prelabor rupture of

membranes and septicemia may occur in 5-10% of such

settings. A wide variety of bacteria present in the normal

vaginal flora of pregnant women such as anaerobes and

Escherichia coli can also cause ascending infections,

usually after rupture of membranes, resulting in

intraamniotic infection. Chorioamnionitis resulting from

such infections can lead to preterm labor and fetal


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morbidity and in the newborn, were important causes of

septicemia and meningitis.

Considerable evidence derived from animal

studies shows administration of bacteria in pregnant

animals can induce preterm labor and subsequent

neonatal morbidity or mortality. Systemic maternal

infections have also been associated with preterm labor

and neonatal complications. The rate of preterm delivery

associated with pneumonia ranges from 15-48%. The

Gold standard for diagnosing intrauterine infection is a

positive culture of amniotic fluid collected aseptically via

transabdominal amniocentesis which that is invasive.

Microorganism gain access to the amniotic cavity by

ascending from vagina and cervix, hematogenous

dissemination (transplacental), retrograde seeding from

peritoneal cavity through the fallopian tube, and accidental

introduction at the time of invasive procedure. Of these

mentioned, the most common pathway is the ascending

route of infection. Studies have shown that in virtually

all cases of congenital pneumonia, inflammation of

chorioamniotic membrane is present. Other studies also

show that bacteria identified in cases of congenital

infection are similar to the bacteria isolated from the lower

genital tract.

Intraamniotic infection is difficult to diagnose.

Clinical criteria includes maternal fever, maternal or fetal

tachycardia. The infection may be polymicrobial, but

collecting amniotic fluid samples without contamination

of normal vaginal flora requires invasive procedure. A

number of studies have shown a correlation between

vaginal infections and preterm birth, The most advanced

and serious stage of ascending infection is fetal infection.

The nose and the external ear canal in the

newborn infants have bacterial colonizers and in one study

done among infants < 7 days old, they noted that the

newborn’s nose has this pattern of bacterial colonization:

normal flora (39%); potentially pathologic gram-positive

microorganisms (23%); gram-negative enteric rods

(16%); and sterile cultures (22%). The most frequent

bacterial isolates from nostrils were Staphylococcus

epidermidis (39%); Staphylococcus. aureus (11%) and

Escherichia coli (8%). The cultures from the external

ear canal showed normal flora (37%); potentially

pathologic gram-positive microorganisms (5%); gram-

negative enteric rods (24%); and sterile cultures (34%).

The most frequent bacteria cultured from the ear canal

were: Staphylococcus. epidermidis (37%); E. coli

(8%); and Klebsiella pneumoniae (7.5%).1

In another study, Gram positive septicemia the

commonest site for colonization of the same organism in

newborn was found to be umbilicus followed by nose,

throat and external auditory canal, while in Gram negative

septicemia rectum and umbilicus were the commonest

sites.2

Oropharyngeal fluid aspirates have not yet been

explored yet. In utero, the fetus swallows amniotic fluid.

The aspirate that is present in the newborns oropharyngeal

area may represent the environmental milieu that the

newborn is exposed to while in utero. Swallowing

potentially septic amniotic fluid may predispose the

newborn to sepsis. Thus, will an initial oropharyngeal fluid

aspirate culture reflect the blood culture of potentially

septic neonates?

DEFINITION OF TERMS

Potentially septic neonates included in the study

are those that have the maternal risk factors of infection

that occurred in the last trimester of pregnancy. This

includes maternal fever alone, maternal urinary tract

infection (dysuria, vaginal discharge), maternal respiratory

tract infection, prelabor rupture of membranes, and

spontaneous preterm labor. Maternal fever as a risk factor

is defined in this paper as the presence of temperature

of more than 37.5° C with no other symptoms and signs

pertaining to a focus of infection. Prelabor rupture of

membranes denotes spontaneous rupture of fetal

membranes before the onset of labor, whether term of

preterm. Pregnancies with intact fetal membranes and

spontaneous preterm labor must be distinguished for

clinical as well as for research purposes from those in

which there has been rupture of membranes. Preterm

labor is precisely defined as spontaneous onset of labor

occurring before the 37 completed weeks or 259

completed days of gestation, without any other symptoms

and with intact fetal membranes. If the pregnant mother

was having symptoms of dysuria with fever, and had a

midstream, clean-catch urinalysis showing elevated Urine

WBC of more than 5 per high power field and/or urine

culture with more than 100,000 colony-forming units of a

single organism per 1mL of urine then she was considered

as having maternal urinary tract infection. The presence

of cough and/or colds with associated fever was

categorized as having respiratory tract infection.

Neonates were followed up and their morbidities

that occurred within 72 hours were noted. Jaundice for

the purpose of this study was defined as having yellow

skin discoloration with an elevated total bilirubin levels

increasing >5mg/cL per day, >12 mg/dL in a term infant

and >15mg/dL in a preterm infant, direct bilirubinemia

>2mg/dL and the jaundice lasted for more than 1 week.

Infants categorized as having jaundice had jaundice alone

as their main symptom with no other associated

symptoms of disease Those that were labeled as having


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pneumonia were neonates that developed respiratory

distress, rales on lung fields and abnormal temperature

patterns. Necrotizing enterocolitis was defined as

feeding intolerances (residuals, abdominal distention,

vomiting) that were associated with plain abdominal

studies supporting the diagnosis (presence of ileus,

pneumatosis intestinal or pneumoperitoneum). The

neonate was labeled as having sepsis if the neonate had

a blood culture isolate and had clinical signs and symptoms

compatible with sepsis like hypothermia, hyperthermia,

poor suck, lethargic.

The use of initial oropharyngeal fluid aspirate as

an alternate means to reflect the possible isolate in the

neonate is thought of because the fluid in that anatomical

body part reflects the intrauterine environment that the

neonate was exposed to. This aspirate was the first

isolate that we usually obtain in the newborn because

suctioning of the oropharyngeal area was part of initial

resuscitation. And because the collection of the specimen

is done within minutes from birth, it is not much affected

by external, internal and temporal factors.

Only symptoms that developed within 72 hours

of life were noted since symptoms after 72 hours of life

were more of acquired than congenital. Presence of

growth in the blood culture was the gold standard in

determining infection.

OBJECTIVES

This study aims to identify bacterial isolates in

the oropharyngeal fluid of potentially septic neonates

delivered from mothers with infection risks. The initial

blood culture will be correlated with the oropharyngeal

fluid isolate. This study aims to identify if the initial

oropharyngeal fluid aspirate correlates with the causative

organism causing sepsis in the neonate. If this has a

relationship then, the use of a more non-invasive and less

expensive laboratory examination as an alternate is an

option.

This study aims to see if development of

symptoms of infection within 72 hours of life correlates

with the presence of growth in the oropharyngeal fluid

aspirate. Symptoms developing immediately within 72

hours of birth and the result of oropharyngeal fluid aspirate

may predict the result of the blood culture.

METHODOLOGY

Neonates admitted via vaginal delivery in the

OBAS, PGH were be selected. Patients that were

excluded were those who had no maternal risk for

infection and those born via caesarian section. Those

included in the study were patients whose mothers had

a high risk of amniotic fluid contamination like maternal

infection in the last trimester, prelabor rupture of

membrane or preterm labor.

The sample size was computed assuming

maximum variability with a margin of error of 0.1. The

sample size needed for the study is 96 subjects.

A protocol was submitted to the adviser and a

copy was sent to Research Information and Development

Office for ethical review and for registration.

Informed consent was obtained prior to the

delivery of the newborn subject. The fluid in the

oropharyngeal area was obtained observing the aseptic

technique. A syringe was attached to a suction tip to

aspirate the oropharyngeal fluid before the newborn was

suctioned using high negative pressure wall suction. The

specimens were placed in a sterile vial with 1cc of sterile

NSS and was sent to the Microbiology Laboratory for

bacterial studies. Concommitantly, a baseline blood

culture was extracted, using only 1 site and 1 bottle. The

specimen was sent to the Microbiology Laboratory for

culture.

Factors that were considered and noted during

the neonate’s hospital stay during the first 72 hours of

life were the development of illness such as jaundice,

necrotizing enterocolitis, pneumonia and sepsis.

The study design is a prospective risk analytical

study. The difference between the presence or absence

of morbidities and maternal risk factors were compared

using independent samples t-test.

RESULTS

A total of 107 subjects fit the inclusion criteria.

Table I below shows the maternal risk factors of babies

who were included in the study

The neonates were followed up within 72 hours

and the table II shows the morbidities that occurred.

Table I- Maternal Risk Factors

Maternal risk Frequency Percent

Factors

Prelabor Rupture of Membranes 15 14.02

Spontaneous Preterm Labor 34 31.78

Urinary Tract Infection 38 35.51

Respiratory Tract Infection 15 14.02

Fever alone 2 4.67

Total 107 100.00


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Table II- Neonatal Morbidities

Neonatal Morbidities Frequency Percent Cum

None 30 28.04 28.04

Jaundice 50 46.73 74.77

Pneumonia 17 15.89 90.65

Necrotizing enterocolitis 7 6.54 97.20

Sepsis 3 2.80 100.00

Total 107 100.00

Of the 107 subjects, 33.6% had oropharyngeal

aspirate growth and 8.4% had blood culture growth.

Among the subjects who have (+) oropharyngeal aspirate

growth, 25% have a concomitant blood CS growth,

irregardless of the organism isolated. Of the subjects

who had growth on their blood culture, 77% had the same

organism isolated in their oropharyngeal aspirate.

Table III- Oropharyngeal aspirate growth

Sensitivity: 1.0000 (0.6637, 0.9910)

Specificity: 0.7245 (0.6237, 0.8074)

Predictive Value Positive: 0.2500

Predictive Value Negative: 1.0000

Lower bound Upper bound

Likelihood

Ratio (+): 3.6296 2.1628 4.8900

Likelihood

Ratio (-): 0.0000 0.0080 0.5160

There was a significant difference among the

maternal risk factors with regards to presence of

oropharyngeal aspirate growth. Of all the maternal risk

factors, prelabor rupture of membrane has the highest

positive to negative ratio of oropharyngeal aspirate

growth.

Oropharyngeal aspirate Frequency Percent

None 71 66.36

Bacillus sp 2 1.87

Candida 2 1.87

Escherichia coli 6 5.61

Klebsiella pneumonia 2 1.87

Klebsiella rhinoscleromatis 2 1.87

Staphylococcus aureus 2 1.87

Streptococcus epidermidis 12 11.21

Streptococcus viridans 3 2.8

Acinetobacter baumanii 2 1.87

Alkaligenes faecalis 2 1.87

Enterobacter claocae 1 0.93

Total 107 100.00

Table IV- Blood culture growth

Blood Culture Frequency Percent

None 98 91.59

Escherichia coli 5 4.67

Streptococcus epidermidis 1 0.93

Acinetobacter baumanii 1 0.93

Alkaligenes faecalis 2 1.87

Total 107 100.00

Table V- Sensitivity and specificity of Oropharyngeal

aspirate culture as plotted against Blood Culture

Test Blood Blood Total

CS (+) CS (-)Oropharyngeal aspirate

culture positive 9 27 36

Oropharyngeal aspirate 0 71 71

culture negative

Total 9 98 107

Table VI- Maternal Risk Factor Contributing to Presence of

Oropharyngeal aspirate Growth

15

34

38

15

5

107

Fisher’s exact = 0.001

Maternal Risk Factor Oropharyngeal Total

aspirate

No With

growth(%) growth

Prelabor Rupture of

Membranes

Preterm Labor

Urinary Tract Infection

Respiratory Tract Infection

Fever

Total

3 12

20% 80%

27 7

79.41% 20.59%

26 12

68.42% 31.58%

12 3

80% 20%

3 2

60% 40%

71 36

66.36% 33.64%


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Sensitivity : 1.0000 (0.5407,0.9864)

Specificity : 0.7273 (0.3952,0.9256)

Predictive value positive : 0.6667

Predictive value negative : 1.0000

Table VII- Neonatal jaundice

Table VIII- Neonatal pneumonia


CS (-) CS (+)

Oropharyngeal fluid aspirate (-) 8 0 8

Oropharyngeal fluid aspirate (+) 3 6 9

Total 11 6 17


CS (-) CS (+)



Total 50 0 50


CS (-) CS (+)



Total 30 0 30

Lower Upper

Bound Bound

Likelihood Ratio (+): 3.6667 1.3918 9.6124

Likelihood Ratio (-): 0.0000 0.0119 0.7335

Table IX- No symptoms

DISCUSSION

The noted limitation of this study is a small sample

size with a wide margin of error, making wide confidence

interval and thus compromising the precision. This study

has some biases, as not all mothers with risk factors,

who have potentially septic neonates, were recruited. The

recruitment of subjects and collection of specimen is

according to the time that is convenient to the investigator.

Confounding factor identified in the study is the

administration of antibiotics to the mother. To delimit,

larger population must be included, ideally all who have

risk factors. However, the confounding factor of antibiotic

use cannot be controlled as it would be unethical to defer

administration of antibiotics if the clinical suspicion of

infection is likely.

The most common maternal risk factor of

neonates noted is urinary tract infection, however,

majority of them have no oropharyngeal fluid bacterial

growth. There are only fifteen (15) neonates with

maternal risk factor of prelabor rupture of membrane,

but it can be noted that 80% of them have oropharyngeal

bacterial growth. The highest blood:oropharyngeal

aspirate bacterial growth ratio is the Escherichia coli.

Cross-examination of variables in Tables VII to IX will

show that among neonates who developed jaundice had

no bacterial growth in their blood however 34% of them

have oropharyngeal fluid aspirate growth. It is important

to note that in table VIII, where neonates who had

pneumonia, all of the neonates who had bacterial growth

in the oropharyngeal fluid aspirate also has bacterial

growth in their blood. Those neonates who had no

symptoms within the first 72 hours of life had no bacterial

growth in their blood; however 4 of them have an isolate

from the oropharynx. It is noteworthy that the bacterium

isolated from their oropharynx is Staphylococcus

epidermidis, which can be attributed as collection error

probably because of aseptic technique.

CONCLUSION

The sensitivity of oropharyngeal fluid aspirate

culture irregardless of the organism isolated is 100%, the

sensitivity is 72.35%. However this is not as reflective

of the true sensitivity and specificity as there is a wide

margin of error. Prelabor rupture of membrane has the

highest risk of having bacterial growth in the neonates’

oropharyngeal fluid. Patients with neonatal pneumonia

who have bacterial growth in the oropharyngeal fluid have

a high percentage of having bacteremia.

RECOMMENDATION

A further study with a larger sample size to have

a narrower margin of error is recommended.


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REFERENCES

1. Bergstrom,S. Infection-related morbidities in the mother,

fetus and neonate. The American Society for Nutritional

Sciences. 2003, May; 133: 1656-1660.

2. Purwar,M., Ughade, S., Bhagat, B., Agarwal, V. & Kulkarni,

H. (2001) Bacterial vaginosis in early pregnancy and

adverse pregnancy outcome. J. Obstet. Gynaecol. Res.

27: 175–181.

3. Blanco, J. D. (1998) Clinical intra amniotic infection. In:

principles and practice of medical therapy in pregnancy

(Gleicher, N. ed., Gall, S. A., section ed.), pp. 853–857. 3rd

edition. Appleton and Lange Stamford, CT.

4. Segal, OE, et al. Bacterial colonization of the nose and

external ear canal in newborn infants. Israel Journal of

Medical Science. 1983 Dec; 19(12).

5. Bhatia, BD, et al. Bacterial flora in mothers and babies

with reference to causative agent in neonatal septicemia.

Indian Pediatrics. 1989 May; 26(5).

6. Romero R, et al. The role of infection in preterm labor and

delivery. . Paediatric and Perinatal Epidemiology 2001,

14 (Suppl 2), 41-56


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RETROSPECTIVE ANALYSIS OF THE CLINICAL PROFILE AND

IMMEDIATE OUTCOME OF PEDIATRIC PATIENTS DIAGNOSED WITH

PLEURAL EFFUSION OR EMPYEMA THORACIS, ADMITTED TO A

TERTIARY GOVERNMENT HOSPITAL DURING JANUARY 1998 TO

DECEMBER 2000

ABSTRACT

Objective: To review the clinical characteristicsors of

patients who developed complicated and non-complicated

effussions

Design: This study was a case review over a 3-year

period (Jan. 1, 1998 to Dec. 31, 2000) of medical records

of children aged 3 months to 17yrs with a final diagnosis

of pleural effusion or empyema thoracis

Setting: A tertiary government hospital

Results: Sixteen (16) case records diagnosed with pleural

effusion or empyema thoracis from a primary non-

tuberculous respiratory tract infection were reviewed as

to demographics, duration of illness, presenting symptoms,

coexisting illness, clinical and laboratory results, and

outcome. Of the 16 cases, 6 had non-complicated

resolution of parapneumonic pleural effusion while 9 had

chest tube thoracostomy inserted. The duration of

confinement for complicated effusions was significantly

longer (p-value 0.019) than those of non-complicated

parapneumonic effusions.

Conclusion: The presenting signs and symptoms of

patients with pleural effusion are febrile, cough, productive

cough, dyspnea, and chest pain. The development of

complicated parapneumonic effusion is correlated to a

prolonged duration of confinement (p-value 0.019).

INTRODUCTION

Pleural effusion is the accumulation of pleural

fluid within the pleural space beyond which the lymphatic

system can remove. This may be due to many causes

including thoracic diseases, trauma, and iatrogenic injury,

but the most common of which is infection. It has been

said that as many as 40% of hospitalized patients with

bacterial pneumonia have an accompanying pleural

effusion.1 However, only about 10% of these cases need

operative intervention for their resolution. It is in these

Dexter D. Cheng, MD*, Alexander O. Tuazon, MD*

conditions that the morbidity and mortality rates are

increased.2

Empyema thoracis by definition is pus in the

pleural space. Light describes this as pleural effusions

with thick, purulent appearing pleural fluid.1 However,

he goes on to elaborate parapneumonic effusions as any

pleural fluid associated with bacterial pneumonia, lung

abscess, or bronchiectasis. In contrast, complicated

parapneumonic effusions, to which empyema thoracis

belongs, refer to those effusions that do not resolve without

tube thoracostomy.iii

Empyema thoracis is a problem that has been

recognized for centuries.1 Again, there are many causes,

but it is an infected parapneumonic effusion that is the

most common cause.2 Early diagnosis and aggressive

management is necessary to prevent decreased pulmonary

function and the local and systemic sequelae of active

infection. Delays in diagnosis will allow the empyema to

become organized, at which point, percutaneous drainage

techniques and systemic antibiotics are ineffective.

It is the objective of this eview to determine

whether there are clinical factors that may predispose to

the development of complicated parapneumonic effusions

and empyema thoracis. If such factors do exist, then early

surgical managment may be instituted.

GENERAL OBJECTIVES

1. To determine the clinical characteristics of patients

that will correlate with a diagnosis of complicated

effusion.

2. To determine and compare non-complicated and

complicated effusion in relation to the following

outcomes:

a. Length of hospital stay

b. Complications

c. Mortality


Keywords: pleural effusion, empyema thoraces


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Specific Objectives

1.To determine whether patient factors (age, sex, birth

order, social class, presenting illness, duration of illness,

etc, will correlate with the development of complicated

effusion

2. To determine and compare the duration of

confinement in days of patients with non-complicated

pleural effusion and complicated effusions.

3.To determine and compare the complications of

patients with non-complicated pleural effusion and

complicated effusions.

4. To determine and compare the mortality rate of

patients with non-complicated pleural effusion and

complicated effusions.

METHODOLOGY

A retrospective review of medical records of

children aged 3 months to 17 years admitted to a tertiary

medical center with a final diagnosis of pleural effusion

or empyema thoracis from January 1998 to December

2000 was included in the study.

DEFINITIONS

A. Non-Complicated pleural effusion is the accumulation

of pleural fluid within the pleural space

B. Complicated effusions are those effusions that satisfy

the criteria defined by Light1 as follows:

1. pH of pleural fluid less than 7.0

2. pleural fluid glucose less than 60 mg%

C. Empyema thoracis is effusion with thick, purulent

appearing pleural fluid

EXCLUSION CRITERIA

a. Patients receiving chemotherapy or radiotherapy.

b. Patients diagnosed with tuberculous effusions.

c. Patients who are admitted within 10 days from a

previous hospitalization.

d. Patients who are transferred from another hospital.

A total of 82 cases were identified. However, a

total of 56 were excluded because 50 were of tuberculous

etiology, 5 were nosocomial pneumonias from other

hospitals, and 1 was traumatic in origin. Data collected

from the remaining 16 cases included demographics,

presenting symptoms and duration of illness, coexisting

illness, clinical and laboratory results, and outcome.

RESULTS

Sixteen (16) case records diagnosed with pleural

effusion or empyema thoracis from a primary non-

tuberculous respiratory tract infection were reviewed.

They ranged in age from 6 months to 202 months (mean

86 months). Seven (44%) were male. All cases were

confined at the charity ward. 11 cases (69%) were the

3rd born or younger. The duration of illness ranged from

4 to 60 days (mean 26 days). Common presenting

symptoms were pyrexia, cough, productive cough,

dyspnea, and chest pain (Table 1). Nine (9) cases (57%)

had intake of antibiotics either through self-medication

or through a physician prior to consult at the tertiary

hospital. One patient had acute gastroenteritis while the

other 15 did not have any concomitant illnesses at the

time of consult.

Of the 16 cases, 6 had non-complicated resolu-

tion of parapneumonic pleural effusion while 9 had chest

tube thoracostomy inserted. Of the latter, 5 were dis-

charged with open tube thoracostomy in place (Table 2).

The duration of confinement, as shown in table

2, for complicated effusions ranged from 15 to 45 days

(mean 29 days), while those with non-complicated

effusions ranged from 4 to 22 days (mean 10 days). There

was 1 case of nosocomial pneumonia in a patient with

complicated effusion. There were no cases of

pneumothorax nor were there any mortalities.

Table 2. Outcome of 16 Cases of Pleural Effusion

Type of

Effusion

Complicated

Non-

complicated

Number

of Cases

10

6

Average

Duration of

Confinement

(Days)

29

10

Number

Discharged

with

OpenTube

Thoracostomy

5

N/A

Table 1. Presenting Symptoms in 16 Patients Diagnosed

With Pleural Effusion or Empyema Thoracis

Symptom

Febrile

Cough

Productive cough

Dyspnea

Chest Pain

Weakness

Number (%)

15 (94)

15 (94)

11 (69)

11 (69)

7 (44)

1 (7%)


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DISCUSSION

Pleural effusions and empyema thoracis are

relatively common and are associated with significant

morbidity and mortality. Treatment is directed at

controlling the infection and maximizing pulmonary

function.1 Delays in the diagnosis will significantly

increase morbidity and will result in a prolonged clinical

course.vi Furthermore, valuable medical resources are

consumed that may not necessarily influence patient

recovery. These assets are important considerations

most especially in this setting of constrained medial care.

This study focused on non-tuberculous

parapneumonic pleural effusions and empyema thoracis.

The demographics, duration of illness, presenting

symptoms, coexisting illness, clinical and laboratory

results, and outcome were reviewed. However, there

was no statistical significance in the results that correlates

to the development of complicated effusions. The

presenting symptoms noted correlate with those in other

studies.1

The diagnosis of effusion was based on the history

and physical examination, together with chest

roentgenogram and pleural fluid analysis. The criteria

were as described by Light.vi The outcome of pleural

effusion is dependent on the stage of the disease.

Complicated effusions that become organized will no

longer respond to percutaneous drainage and systemic

antibiotics alone. vi Many factors are believed to

contribute to its development. These include prolonged

duration of illness, prior antibiotic intake, and delay in

proper diagnosis. These three factors, however, were

not shown to be statistically significant with the

development of complicated effusions in this review.

The duration of confinement for patients with

complicated effusions was shown to be significantly

longer in this review (p-value 0.019) of 16 cases. The

small sample failed to show any difference in the

incidence of morbidities and mortalities.

In our setting, most cases of both complicated

and non-complicated effusions are secondary to or are

complicated by pulmonary tuberculosis. In this 3-year

review, tuberculous effusions accounted for 68% of all

cases while parapneumonic effusions accounted for 20%.

CONCLUSION

In the review of cases over the three years from

January 1998 to December 2000, only 16 cases of

bacterial parapneumonic effusion were seen. The

presenting signs and symptoms of patients with pleural

effusion are febrile, cough, productive cough, dyspnea,

and chest pain.

Due to the small sample size, the statistical power

is weak and differences are not readily observed. The

only significant result was the correlation of prolonged

hospitalization with the presence of complicated pleural

effusions (p-value 0.019). In order to further elicit any

probable relationships, a larger sample size is needed. It

is suggested that the review include several other tertiary

hospitals and to increase the duration of the review.

REFERENCES

1. Light RW, Girard WM, Jenkinson SG, George RB:

Parapneumonic effusions. Am J Med 1980; 69: 507-511.

2. Brewin A, Arango L, Hadley WK, Murray JF: High-dose

penicillin therapy and pneumococcal pneumonia. JAMA

1974;230:409-413.

3. Light, RW: Pleural Diseases; 3rd Edition. William and

Wilkins 1995: 130.

4. Hippocrates. Genuine works of Hippocrates. Translated

by F. anderer. London (UK): Syndenham Society; 1847.

5. LeMense GP, Strange C. Sahn SA: Empyema thoracis:

therapeutic management and outcome. Chest 1995;

107:1532-7.

6. Light RW: Pleural diseases, 3rd Edition. William and

Wilkins 1995: 138-142.

7. Shaknar KR, Kenny SE, Okoye BO, Carty HM, Lloyd

DA, Losty PD: Evolving experience in the management

of empyema thoracis. Acta Paediatr 200 Apr; 89(4): 417-

20.

8. Chu M, Dewar L, Burgess J, Busse E: Empyema thoracis:

lack of awareness results in a prolonged clinical course.

J Canadien de Chirurgie 2001; 44(4): 284-288.


12

A RANDOMIZED PLACEBO-CONTROLLED TRIAL ON THE USE OF

PROBIOTICS IN THE PREVENTION OF NOSOCOMIAL INFECTION IN

PEDIATRIC PATIENTS WITH HEMATOLOGIC AND ONCOLOGIC

DISEASES

Arlene Grace L. Simon, MD*, Jossie Rogacion, MD*

ABSTRACT

Background: Despite measures to decrease its

incidence, nosocomial infection remains to be a major

problem in most tertiary hospitals. The use of prophylactic

antibiotics leads to an increase in bacterial resistance,

rather than decreasing the nosocomial infection rate.

Other measures have been proposed to combat antibiotic

resistance and the development of nosocomial infection,

such as the use of probiotics.

Objective: The efficacy of the use of probiotics in the

prevention of nosocomial infection and effect on duration

of hospitalization was tested in patients with hematologic

and oncologic diseases.

Study design: Randomized placebo-controlled double-

blind trial using placebo and probiotics.

Intervention: 50 patients out of 76 predicted sample size,

with hematologic and oncologic diseases who had a

minimum predicted duration of hospitalization of 3 days

were enrolled in a double-blind trial and randomly assigned

on admission to take either 1 capsule of probiotics (n=25)

containing at least 1.5 billion cells of Lactobacillus

acidophilus, Bifidobacterium bifidus and

Bifidobacterium longus or a comparable placebo (n=

25) once daily during their whole hospital stay. The

patients were monitored and assessed daily for the

development of nosocomial infection and for compliance

to administration of the capsules. The patients were also

assessed for any possible adverse effects. The counting

of the duration of hospital stay started from admission to

the emergency room till discharge. Patients were asked

to follow up 1 week after discharge.

Results: This paper presents the preliminary results of

the study involving 50 patients. Baseline characteristics

on admission were found to be similar. The use of

probiotics prevented the occurrence of nosocomial

infection in patients with hematologic and oncologic

diseases as compared to those receiving placebo, 0% vs.

20%, with a relative risk of 0.2 (fisher’s exact test= 0.025,

p< 0.05). However, there was no significant statistical

difference between the duration of stay of the 2 groups

(placebo = 9.4 days compared to probiotics = 8.6 days).

The difference in readmission was analyzed using z-test

and was also found to be not statistically significant. No

adverse effects were reported in both groups.

Conclusion: The use of probiotics in patients with

hematologic and oncologic diseases may play a role in

the reduction of the occurrence of nosocomial infection,

but may not necessarily cause a reduction in the duration

of hospital stay. Further confirmation of the results is

recommended upon completion of the study.

INTRODUCTION

Measures have been proposed to prevent the

occurrence of nosocomial infection in most tertiary

hospitals, such as strict hand-washing, the use of gowns,

masks and gloves and the segregation of wards into

infectious and non-infectious cases.1 However,

nosocomial infection still remains to be a major problem.

It prolongs the stay of the patient in the hospital and is a

cause of additional financial burden to the family of the

patient. Patients afflicted with chronic illnesses, such as

those with hematologic and oncologic diseases are said

to be particularly susceptible to nosocomial infection due

to the secondary impairment of their immune response.

The use of chemotherapy, in particular, contributes to the

impairment of the immune response of oncologic patients.1

Prophylactic antibiotics may be given to prevent the

occurrence of opportunistic infections in oncologic

patients. However, the use of prophylactic antibiotics may

lead to the emergence of resistance to these antibacterial

agents and may even lead to the depletion of good

microorganisms. It is this growing emergence of

resistance to antibacterial agents which gave birth to

bacteriotherapy. Bacteriotherapy is the use of harmless

bacteria to displace pathogenic organisms and is said to

be an alternative and promising way of combating

infection.2

Keywords: probiotics, nosocomial infection, hematologic, oncologic, duration of hospitalization.



13

Probiotics are live microorganisms which colonize

the intestine, modifying the intestinal microflora and their

metabolic activities, leading to presumed beneficial

effects to the host system.3 Probiotics are said to be

non-pathogenic because they naturally inhabit the human

intestine. The use of probiotics in diarrhea have been

proven by numerous studies. These studies have shown

that probiotics prevent the occurrence of diarrhea, as well

as lessen it severity by promoting the growth of these

beneficial live microorganisms and preventing the

overgrowth of harmful microorganisms by means of their

direct effect on the intestinal mucosal system.4 It is said

to promote healing of the intestinal mucosa by reducing

gut permeability and by enhancing the local intestinal

immune response.3 A study on the prevention of

nosocomial diarrhea on infants was undertaken in Poland

by Szajewska et. al. Lactobacillus GG was given to

hospitalized infants and the results showed that probiotic

supplementation caused a decrease in the occurrence of

nosocomial diarrhea (6.7% vs. 33.3%), with a resulting

decrease in the length of stay of the patients given

Lactobacillus GG.5

Recently, it has been postulated that probiotics

may be beneficial not only in the gastrointestinal tract

which they normally inhabit, but also in other mucosal

surfaces such as the respiratory tract and urinary tract

systems. It has been postulated that probiotics produce a

beneficial effect on the over-all host system because of

its’ effect on both the humoral and cellular immune

systems. A study in Finland by Hattaka et. al. explored

the use of milk cultured with probiotics in the prevention

of respiratory and gastrointestinal infections in healthy

children attending day care centers.6 The study showed

a significant decrease in the number of absences due to

respiratory and gastrointestinal illnesses in the children

supplemented with probiotics compared to the placebo

group (16% difference). There have been no studies,

however, regarding the use of probiotics in children

afflicted with chronic illnesses.

This study was conducted to determine if

probiotics can be used in the prevention of the occurrence

of nosocomial infection in children with hematologic and

oncologic diseases.

OBJECTIVES

General Objectives

To determine if supplementation with probiotics

will improve the outcome of hospitalized pediatric patients

with hematologic or oncologic diseases.

Specific Objectives

To determine if hospitalized pediatric patients

with hematologic or oncologic diseases given probiotic

supplements will have a lesser frequency of nosocomial

infections compared with hospitalized patients given

placebo.

To determine if patients with probiotic

supplementation will have a shorter duration of

hospitalization as compared with patients given placebo.

Definition of Terms

Probiotics – nutritional supplements containing live

bacterial or yeast cultures which commonly inhabit the

intestinal system.3

Hematologic diseases – disorders that produce either

quantitative or qualitative defects involving the cellular

elements of the blood and blood tissues and those affecting

hemostasis, such as in aplastic anemia and hemophilia.7

Oncologic diseases – diseases which cause proliferation

of abnormal cells called oncogenes producing cancer and

proliferation of tumor suppressor genes, such as in

leukemia and retinoblastoma.7

Nosocomial infection - infections appearing in hospitalized

patients not present nor incubating at time of admission

from the hospital. The onset is beyond 72 hours from

admission to the hospital, starting from admission to the

emergency room.

METHODOLOGY

Setting

This randomized, double blind, placebo-controlled

clinical study was conducted at the Philippine General

Hospital Pediatrics wards and Emergency Room from

July to October, 2002.

Patient Recruitment

Children aged 1 to 16 years of age with

hematologic or oncologic diseases, with a predicted length

of hospital stay of at least 3 days were recruited in the

study consecutively upon admission at the Pediatric

Emergency Room. The conduct of the research was

explained to the parents by the investigator and written,

informed consent was secured prior to enrollment in the

study. Children who were placed on nothing per orem,

with known allergy to cow’s milk, other concomitant

disorders, those who were in severe respiratory distress

needing oxygen and ventilatory support, as well as those

with neurologic deficits such as signs of increased

intracranial pressure due to intracranial bleed and patients


14

with assessment of nosocomial infection on admission

were excluded from the study. All the patients whose

parents gave written, informed consent were randomized

for the trial.

Sample Size Computation

Sample size was calculated based on the

assumption that the use of probiotics will result in a 20%

reduction in the occurrence of nosocomial infection. This

assumption was based on an earlier study by Szajewska

et. al.,5 which reported a 26.6% decrease in the

occurrence of nosocomial diarrhea (33.3% in the control

group) in normal children. It was estimated that with a

power of 90% and at alpha level of 0.10, we needed 38

children per group to show a 20% difference.

Randomization

The patients were recruited as they arrived at

the Pediatric Emergency Room. The patients were

randomized into the 2 groups by means of a computer

generated randomization table.

Random Allocation/Blinding

The GNC Kyo-dophilus® (probiotics) capsules

were repackaged by the Industrial Pharmacy laboratory

of the University of the Philippines, Manila into yellow

size 1 capsules. The same laboratory prepared the

placebo capsules and packaged the cornstarch placebo

into the same yellow size 1 capsules. This repackaging

was necessary to ensure that the physicians and the

patients will be blinded during the study. A person not

directly involved in care of the subjects was tasked to

encode the capsules into 2 groups (1 and 2). The capsules

were packaged in air-tight envelopes (7 capsules per

pack) labeled 1 or 2 with the corresponding patient number

and patient name. Both the physician in charge and the

patients were unaware of which capsules contain

probiotics or placebo. The code was revealed during the

data analysis.

Intervention

On admission to the study, complete history and

physical examination were performed. The patients

included in the study were given either 1 capsule of

probiotics or placebo everyday from day 1 of ER

admission until the last hospital day. In the event that the

patients get admitted to the wards, intervention and

monitoring were continued until discharge. One capsule

of the GNC Kyo-dophilus® probiotics contains a minimum

of 1.5 billion live cells of Lactobacillus acidophilus,

Bifidobacterium bifidum and Bifidobacterium longum. The

probiotic capsules were lyophilized, ensuring stability in

room temperature.

The mothers were given a set of 7 capsules on

admission. The mothers were instructed to give their

children 1 capsule once a day after the morning meal.

For patients less than 7 years of age or those who had

difficulty in swallowing the capsules, the mothers were

instructed to mix the powdered contents in 1 tsp of milk

to be given after the morning meal. For patients who

vomited the capsules or the powdered contents, the

mothers were given instructions to give another dose 1

hour after the vomiting. The mothers were instructed to

list down difficulties in giving the capsules.

The supplementation was continued until the

patient was discharged from the hospital. Patients who

developed nosocomial infection were instructed to

continue supplementation until discharge. Monitoring for

these patients continued until the patients were discharged

from the hospital. Parents were instructed not to give

their children other products with probiotic organisms.

Infection Surveillance

Baseline laboratories were ordered on the first

hospital day, which included a baseline complete blood

count, chest x-ray, urinalysis, stool exam and blood

culture. The patients were visited daily and were

monitored for the occurrence of nosocomial infection and

compliance to the administration of the drug. The parents

were also instructed to write down problems in

administration and noted adverse effects on

supplementation. Laboratories were repeated depending

on the clinical suspicion of nosocomial infection. The

patients were also followed up 7 days after discharge

and assessed for the development of nosocomial

infection. A diagnosis of nosocomial infection was made

if the criteria for nosocomial infection as drafted by the

Infectious Disease Section of the Department of

Pediatrics of the Philippine General Hospital was fulfilled.

Classification of Nosocomial Infection:

A. Respiratory infection

1. Clinical signs and symptoms of lower respiratory

tract infection (LRTI)

(cough, fever, increase in purulence of secretions,

new auscultatory findings) + new infiltrates on

chest x-ray

1.1 with + culture (ETA/TTA/LT)

1.2 with (-) blood culture


15

2. Clinical signs and symptoms of lower respiratory

tract infection (LRTI) + new infiltrates on chest

x-ray

2.1 with (+) blood culture


B. Urinary tract infection

1. Colony counts of > 100,000/ml of appropriately

collected specimen or visible organism on gram

stain in a patient with previously (-) urine culture

or normal urinalysis

1.1 with no clinical signs and symptoms (fever,

dysuria, costovertebral angle tenderness,

suprapubic tenderness)

2. Colony counts > 10,000 colonies/ml. Of

appropriately collected specimen of a new

pathogen with a previously (+) urine culture:

2.1 with clinical signs/symptoms

2.2 without clinical signs/symptoms

C. Gastrointestinal tract infection

1. Diarrhea with a patient with no diarrhea on

admission

1.1 with (+) stool culture

1.2 with (-) stool culture

2. Any other signs of GI disturbance (nausea,

vomiting, abdominal tenderness) not previously

present on admission (peritonitis, NEC, intra-

abdominal abscess)

2.1 with (+) stool culture

2.2 with (-) stool culture

D. Bacteremia

1. Presence of a (+) blood culture in a patient with

no definite focus of infection

2. Bacteremia with Infective endocarditis

E. Sepsis

1. Signs and symptoms of sepsis (poor suck/activity,

jaundice, acidosis, hypotension, hyperglycemia,

etc.) with definite focus of infection

1.1 with (+) blood culture


Checking of Compliance

The number of remaining capsules and empty

shells were checked daily. Patients whose length of stay

exceeded 7 days were given a weekly supply of 7

capsules. All remaining capsules were returned on the

last hospital day, prior to discharge of the patient.

Outcome Measures

The primary outcome measures were the

absence or occurrence of nosocomial infection as defined

by the criteria for nosocomial infection by the Section of

Infectious Diseases and the number of days the patient

was hospitalized starting from the day of admission at

the emergency room. A secondary outcome was the

number of children with readmissions due to nosocomial

infection within 7 days from discharge.

Withdrawals/Deviations From The Study

Withdrawal is defined as those patients who are

taken out from the study by their parents, those who are

brought home against advice by their parents disrupting

therapy and those who are placed on nothing per orem

for more than 2 days during the duration of the study.

Deviations from the study include those patients who are

placed on nothing per orem for less than 48 hours and

those who vomited the capsules during the initial

administration. The mothers of the patients who were

placed on nothing per orem for less than 48 hours were

instructed to resume administration once feeding, while

the mothers of the patients who vomited during the initial

administration were instructed to re-administer the

capsules 1 hour after the vomiting.

STATISTICAL ANALYSIS

An intention to treat analysis was performed.

Data were analyzed using Statistica software. T-test was

done comparing the difference between the means of 2

independent samples. In comparing the distribution of

discrete variables between two groups, chi-square test

or Fisher’s exact test when appropriate were performed.

The z test was used to determine the significance of

readmissions between the two groups. All tests were

performed at a significance level at p < 0.05.

RESULTS

A total of 56 patients out of 76 predicted sample

size, with hematologic and oncologic diseases were

recruited for the study and randomized using a computer

generated blocked randomization table. Of the 56 patients

recruited, 6 patients were still hospitalized at time of

analysis and were not included in the partial analysis of

this study. This paper presents the preliminary data

analysis of 50 patients included in the study.

Of the 50 patients discharged, there were 2

withdrawals: 1 from each group and were due to the

patient being brought home per request of the parents.

The patient from the treatment group who was brought

home against advice developed intracranial bleed due to

hyperleukocytosis on the 3rd ward day and was brought

home per request of the parents. This patient did not


16

develop nosocomial infection during the whole hospital

stay. The patient from the control group who dropped

out of the study developed nosocomial pneumonia on the

4th hospital day and was brought home per request

because the parents did not want to push through with

chemotherapy. Since this is an intention to treat type of

study, the data up to the day that these patients dropped

out of the study were included in the analysis.

DESCRIPTION OF STUDY POPULATION

Data gathered on admission (Table 1) revealed

that 74% of the patients were male (n=37) and in the 2-

5 years age group (n=21; 42%). Of the 50 patients

included in the data analysis, 26 (52%) had oncologic

diseases while 24 (48%) had hematologic diseases.

Majority of the patients were hospitalized due to fever

(n=20; 40%), followed by pallor (n=15; 30%) as the most

common presenting symptom.

Table 1. Characteristics of patients included in the study

(N = 50)

CHARACTERISTIC

AGE Distribution

2-5 years

6-9 years

10 – 13 years

14 –16 years

Presenting complaint

Fever

Pallor

Bleeding

Diarrhea

Disease Type

Hematologic

Aplastic anemia

Thalassemia

Hemophilia

Others

Disease Type

Oncologic

ALL

AML

Lymphoma

Others

NUMBER

21

11

11

7

20

15

12

3

24

9

6

5

4

26

11

9

2

4

%

42%

22%

22%

14%

40%

30%

24%

6%

48%

37.5%

25%

20.8%

16.7%

52%

42.3%

34.6%

7.6%

15.4%

Comparison of Baseline Characteristics of Placebo

and Probiotic Groups

Table 2 lists the comparison of baseline

characteristics of the 2 groups, such as age, disease type

and presenting complaints. There was no significant

difference in mean age between the placebo group (mean

age = 7.92 years) and the probiotics group (mean age =

7.48 years). With regards to the disease type, it was found

that there are more hematologic patients (n= 14) in the

control group as compared to the treatment group (n =

10). In contrast, the treatment group had more oncologic

(n = 15) patients than the control group (n = 11). This

difference, however, was found to be not statistically

significant, using the Fisher’s exact test. Fever was the

most common presenting complaint in both groups, with

the treatment group having more patients presenting with

fever (11 vs. 9). Again, the difference in presenting

complaints was not statistically significant (x2= 2.3636,

DF =3).

1: t = 0.34, p > 0.05

2: x2 test = 2.3, df = 3, p > 0.05

3: Fisher’s exact test = 0.4, df = 2

DATA ANALYSIS

Frequency of Nosocomial Infection

None of the patients in the treatment group

developed nosocomial infection compared to 20% in the

placebo group (5 out of 25), showing a relative risk

reduction of 100% and an absolute risk reduction of 20%,

with number needed to treat = 5 patients. The difference

was statistically significant using the Fisher’s exact test

(0.025, p< 0.05).

Of the nosocomial infection detected, 1 patient

developed nosocomial candiduria, while 4 patients

developed nosocomial pneumonia. It is noteworthy that

all the patients who developed nosocomial infection are

leukemia patients.

Table 2. Comparison of baseline characteristics of placebo

and probiotic groups

Characteristic

Age (mean) (1)

Presenting

complaint (2)

Fever

Disease type (3)

Hematologic

Oncologic

Control

(N = 25)

7.92 years

9

14

11

Treatment

(N= 25)

7.48 years

11

10

15


17

Table 3. Frequency of patients who developed nosocomial

infection

Duration of Hospitalization

The patients in the placebo group had a mean

duration of hospitalization of 9.4 days (sd = 7.0) as

compared to the probiotics group with a mean duration

of hospitalization of 8.6 days (sd = 6.7; t value = 0.43, p>

0.05).

Secondary Outcome: Readmissions

Of the 25 patients in the probiotics group, 2

patients were readmitted within 1 week due to continuation

of chemotherapy, while in the placebo group, 1 patient

was readmitted for infection, while 2 patients were

readmitted for bleeding and another patient was

readmitted for chelation therapy. None of the 50 patients

had readmissions for nosocomial infection. The data for

re-admissions was analyzed via the z test and was found

to be not statistically significant (z value = - 0.879, α =

0.05; significant z value if < -1.65).

There were no mortalities among the patients

recruited. Of the 50 patients, only 2 patients were

discharged with no improvement. These 2 patients were

the 2 drop-outs who were brought home against advice

by their parents.

All the patients who developed nosocomial

infection received appropriate antibiotic therapy and were

discharged improved.

Surveillence for Adverse Effects

No adverse effects were noted during

supplementation with either the placebo or probiotic

capsules in any of the 50 patients included in the study.

DISCUSSION

This randomized, double blind, placebo-controlled

study is the first of its’ kind to explore the prophylactic

effects of probiotics on nosocomial infection, particularly

in the respiratory, gastrointestinal and urinary tract

systems, in patients with hematologic and oncologic

diseases. The study was undertaken to be able to find a

safe alternative to giving prophylactic antibiotics, which

in the end leads to an increase in antibiotic resistance.

Oncologic and hematologic patients were chosen as the

main subjects in the study because they were found to

be particularly susceptible to developing nosocomial

infection because of their need for frequent admissions

and their exposure to immunosuppressive therapy.

Hematologic and oncologic patients need frequent

admissions due to blood transfusions or chemotherapy.

Baseline characteristics of both groups were

similar and statistical analysis showed that group

differences were not significant. Results revealed that

the treatment group had 0% infection rate as compared

to 20% in the control group. Absolute risk reduction was

100% and relative risk was 0.20, with number needed to

treat = 5. This means that we need to treat only 5 patients

to prevent 1 nosocomial infection. All the patients who

developed nosocomial infection were oncologic patients.

Oncologic patients were found to be more susceptible to

acquiring nosocomial infection due to their impaired

neutrophil counts which decreases the body’s ability to

fight off infection .1 Furthermore, hematologic patients

were found to have a lesser length of stay as compared

to oncologic patients, because most of them get admitted

for blood transfusions only and not for infection or

chemotherapy although the difference did not reach

statistical significance.

The lack of statistical significance with regards

to duration of hospitalization can be explained by the fact

that despite the placebo group having more episodes of

nosocomial infection than the probiotics group, which was

supposed to result in a longer duration of hospitalization,

there were more patients in the placebo group with

hematologic disorders than oncologic disorders as

compared to the probiotics group. Other factors that may

contribute to the lengthening of the duration of stay include

the need for chemotherapy, the procurement of funds

for chemotherapy, as well as the completion of antibiotic

therapy. Despite the lack of difference in the duration of

hospitalization, the decrease in occurrence of nosocomial

infection in the probiotics group implies a better outcome,

since they can proceed to definitive chemotherapy earlier

and there is lesser need for funds to acquire antibiotics

needed to treat nosocomial infection.

Proposed Mode of action:

Probiotics work by being able to replenish the

depleted intestinal microflora which is often caused by

the use of antibiotics.8 It is presumed to promote healing

Placebo Probiotics Total

group group

Nosocomial infection 5 0 5

No nosocomial infection 20 25 45

Total 25 25 50


18

of the intestinal mucosa by reducing gut permeability and

by enhancing the local intestinal immune response,

particularly that of IgA. It is also considered safe and

has no known adverse effects.9

The study in Finland by Hattaka et. al. is the first

to examine if probiotics can also be effective in other

mucosal systems. They hypothesized that probiotics

prevent the occurrence of infection by means of

stimulating non-specific immunity or by enhancing

humoral and cellular immunity.5 Probiotics presumably

prevent respiratory tract infections, even though it is not

in direct contact with it because of its’ stimulatory effect

on secretory IgAat all mucosal surfaces.10

An article published in the Nutrition Hospital

Journal in 2001 promotes the use of probiotics in immuno-

compromised patients, particularly ICU patients. Listed

effects of probiotics in the immune system aside from

stimulating IgA response include the inhibition of IgE

production, stimulation of the macrophage function,

stimulation of the NK activity, stimulation of apoptosis,

promotion of growth and regeneration, reduction of

endotoxin production and the production of anti-

oxidants.11 Further studies are needed to demonstrate

these effects.

CONCLUSION

Probiotics may play a role in the prevention of

the occurrence of nosocomial infection in patients with

hematologic and oncologic diseases, but it may not

necessarily cause a reduction in the duration of hospital

stay.

RECOMMENDATIONS/LIMITATIONS

Since this paper presents only the preliminary

results of the study, further confirmation of the results is

recommended upon completion of the study.

A more objective way of testing compliance

should have been done in the form of stool cultures to

detect the presence of probiotic organisms. Unfortunately,

this was not done due to the unavailability of the test in

the country.

REFERENCES

1. Dix, Kathy. Infection Control in the ICU: The Final Frontier.

Infection Control Today. 2002, June.

2. Huoniven P. Bacteriotherapy: the time has come. British

Medical Journal Aug. 2001;323:353-354.

3. Katelaris P. Probiotics control of diarrheal disease. Asia

Pacific Journal of Clinical Nutrition1996;5:39-43.

4. Agarwal K., Bhasin S., Faridi M., Mathur M., Gupta S.

Lactobacillus cassei in the control of Acute Diarrhea: A

Pilot Study. Indian Pediatrics 2001; 38: 905 – 910.

5. Szajewska H, Kotowska M, Mrukowicz JZ, Armanska M,

Mikolajczyk W. Efficacy of Lactobacillus GG in prevention

of Nosocomial Diarrhea in infants. Journal of Pediatrics

2001, March; 138(3): 361-365.

6. Hattaka K. et. al. Effect of long term consumption of

probiotic milk on infections in children attending day care

centers: double blind, randomized trial. British Medical

Journal 2001; 322:1327-1329.

7. Behrman Richard, Kliegman Robert, Jenson Hal. Nelson

Textbook of Pediatrics. 2000; 16: 1456, 1533.

8. Vanderhoof JA. Lactobacillus GG reduced diarrhea

incidence in antibiotic treated children. Pediatrics 1999,

Nov.; 135:564-568.

9. Wanke C. Do probiotics prevent childhood illnesses?

British Medical Journal 2001; 322: 1318-1319

10. Friedrich M.J., A Bit of Culture for children: Probiotics

may improve health and fight disease. JAMA 2000, Sept.;

284(11):

11. Bengmark S., Garcia De Lorenzo A., Culebras J.M. Use of

Pro, Pre and Synbiotics in the ICU. Nutrition Hospital 2001;

16 (6): 239-256.


19

A FIVE-YEAR RETROSPECTIVE STUDY ON THE COMMON

MICROBIAL ISOLATES AND SENSITIVITY PATTERN ON BLOOD

CULTURE OF PEDIATRIC CANCER PATIENTS ADMITTED AT THE

PHILIPPINE GENERAL HOSPITAL FOR FEBRILE NEUTROPENIA

Ailyn T. Isais-Agdeppa, MD*, Lulu Bravo, MD*

ABSTRACT

Rationale: Febrile neutropenia is a common clinical

problem among pediatric cancer patients. This often

necessitates hospitalization and immediate empiric broad

spectrum antimicrobial therapy. In selecting the initial

antibiotic regimen, the type, frequency and antibiotic

susceptibilities of the microbial isolates should be

considered.

Objective: To determine the bacterial blood isolates and

antimicrobial sensitivity pattern of pediatric cancer patients

admitted at the Philippine General Hospital for febrile

neutropenia.

Methods: Retrospective study of all pediatric patients

diagnosed with a hematologic or oncologic malignancy

admitted at the Philippine General Hospital from January

1999 to December 2003 for febrile neutropenia.

Results: A total of 90 patients were included in the study.

Sixty two per cent (62%) of the subjects were diagnosed

to have hematologic malignancy while 38% are oncologic

cases. Only 7% of the patients had growth in the blood

culture while 93% had no growth in the blood culture.

Causative organisms isolated were Streptococcus

viridans, Gram negative bacilli, Staphylococcus

epidermidis, Candida sp., Salmonella sp. and Haffnea

alveii. All patients received Ceftazidime as empiric

antimicrobial therapy in combination with Netilmycin for

patients admitted in 1999 or Amikacin for patients

admitted from January 2000 to December 2003. S.

viridans, G(-) bacilli, Salmonella sp. and H. alveii

showed sensitivity to Ceftazidime. All patients given

Ceftazidime with Netilmycin/Amikacin became afebrile

on the 3rd day of antibiotics with increasing absolute

neutropenic count except for patients who developed

nosocomial infections causing delay in recovery and

prompting shift of antibiotics.

Conclusion: Majority of pediatric cancer patients with

febrile neutropenia yielded no growth in blood culture.

However, most cases responded well with the empiric

antibiotic combination of Ceftazidime and Amikacin. Few

cases with isolates were also sensitive to the current

antibiotic regimen. The microbiological laboratory should

also act in consultation with the clinician to determine

the optimal approach for blood cultures in the

immunocompromised patients.

INTRODUCTION

Infection and its complications were the main

causes of morbidity and mortality among pediatric patients

receiving chemotherapy for malignant diseases.9

Granulocytopenia carries the risk of bacterial infection.

If prolonged, this can lead to fungal infection. As the

neutrophil count decreases below 500 cells/cu.mm, the

risk of infection increases proportionately.3 Hence,

antimicrobials play a major role in the management of

patient with febrile neutropenia.

International trend shows that gram-positive

bacteria account for 60-70% of microbiologically

documented infections. Some of these are methicillin

resistant. However, gram-negative bacilli especially P.

aeruginosa, E. coli and Klebsiella sp. remain prominent

causes of infection. Fungal infections on the other hand,

are usually superinfections. In some cases, Candida

sp. or other fungi can cause primary infection.6

It is therefore important in the selection of the

initial antibiotic regimen for febrile neutropenia to consider

the type, frequency of occurrence and antibiotic

susceptibility of bacterial isolates recovered from other

patients at the same hospital. Current recommendation

in the empiric antibiotic management of febrile

neutropenia at the Philippine General Hospital is based

on the 1997 Guidelines for the Use of Antimicrobial

Agents in Neutropenic Patients with Cancer prepared

by the Infectious Diseases Society of America (IDSA)

Fever and Neutropenia Guidelines Panel. This

recommends the use of Vancomycin plus Ceftazidime

(or Cefepime) or a carbapenem or combination therapy

with an aminoglycoside plus an anti-pseudomonal beta-Keywords: febrile neutropenia, malignancy, granulocytopenia, absolute neutrophil count, blood

culture



20

lactam as initial intravenous therapy.7 This is based on

international trend of microbiologic growth and sensitivity

pattern.

This study was conceived to determine whether

bacterial blood isolates among pediatric patients with

febrile neutropenia at the Philippine General Hospital is

comparable with the international trend. It aims to provide

local data on the bacterial blood isolates and antimicrobial

sensitivity patterns. This study also hopes to provide

valuable information that will aid in the decision-making

and improvement in the care of pediatric patients with

febrile neutropenia especially in the selection of initial

antibiotic regimen.

DEFINITION OF TERMS

Febrile neutropenia – a single temperature

measurement of >/= 38.3 C in the absence of obvious

environmental causes or temperature of >/= 38.0 C for>/

= 1 hour and granulocytopenia by routine complete blood

count determination Granulocytopenia – absolute

neutrophil count of </= 500 cells/cu.mm.

REVIEW OF RELATED LITERATURE

Children with cancer can be severely

compromised. This can be due to immunodeficiency

secondary to malignancy, the therapy or both. Most

chemotherapeutic agents also inhibit the inflammatory

response to invading microbes. In these patients, the

physical signs and symptoms are not reliable in predicting

infection.3 The neutrophil count on the other hand, is

important in predicting risk and response to infection. As

the absolute neutrophil count goes down, the patient’s

immunological status becomes compromised and the risk

of infection is greater. In such patients with impaired

inflammatory response coupled with granulocytopenia,

fever most of the time is the only sign of infection. This

demands urgent empirical antibiotic therapy with broad

spectrum coverage. This is to decrease the risk of septic

shock, ARDS, hypotension, renal and other organ

dysfunction and death.2

For febrile neutropenia cases, the Infectious

Diseases Society of America (IDSA) recommends a

thorough physical examination, complete blood count,

blood urea nitrogen, creatinine and transaminase level

determination and blood cultures as part of initial

management. Sample for blood culture is drawn from a

peripheral line including a set from central venous access

device. Urinalysis and urine culture is warranted if the

patient has symptoms of urinary tract infection or has a

chronic urinary catheter. Chest radiograph is indicated

when the patient has respiratory symptoms. High

resolution chest computed tomography is requested in

the presence of respiratory symptoms and normal chest

radiographic findings.6

According to the 2002 Guidelines for the Use of

Antimicrobial Agents in Neutropenic Patients with Cancer

published by IDSA, the bacterial causes of febrile

episodes in neutropenic patients are as follows:

Gram-positive cocci and bacilli

Staphylococcus species *

Coagulase-positive (Staphylococcus aureus)

Coagulase-negative(Staphylococcus

epidermidis and others)

Streptococcus species *

Streptococcus pneumoniae

Streptococcus pyogenes

Viridans group

Enterococcus faecalis/faecium *

Corynebacterium species *

Gram-negative bacilli and cocci

Escherichia coli *

Klebsiella species *

Pseudomonas aeruginosa

Enterobacter species

Anaeorobic cocci and bacilli

Bacteroides species

Clostridium species

Fusobacterium species

Propionibacterium species

Peptococcus species

Veillonella species

Peptostreptococcus species

The 2002 Guidelines for the Use of Antimicrobial

Agents in Neutropenic Patients with Cancer published

by IDSA provided the following algorithm in the

management of cancer patients with febrile neutropenia:

* the most common cause of bacteremia

Factors that favor a low risk for severe infection

among patients with neutropenia are absolute neutrophil

count >/= 100 cells/cu.mm, absolute monocyte count of

.>/= 100 cells/cu.mm, normal findings on chest radiograph,

nearly normal results of hepatic and renal function tests,

duration of neutropenia of less than 7 days, resolution of

neutropenia expected in less than 10 days, no intravenous

catheter-site infection, early evidence of bone marrow

recovery, malignancy in remission, peak temperature of

less than 39 C, no neurological and mental changes, no

appearance of illness, no abdominal pain and no

comorbidity complications.6


21

Study Population

The study involved chart review of all pediatric

cancer patients admitted at the Philippine General

Hospital from January 1999 to December 2003 selected

on the basis of the following inclusion criteria: Pediatric

patients aged 1-19 years old diagnosed with oncologic or

hematologic malignancy documented to have

granulocytopenia (neutrophil count </= 500 cells/cu.mm)

by routine complete blood count determination. A single

temperature measurement of >/=38.3 C in the absence

of obvious environmental causes or temperature of >/=

38.0 C for >/= 1 hour no overt site or focus of infection

at the time of admission

DATA COLLECTION

Charts of patients who fulfill the criteria for the

study were retrieved and reviewed. The final blood

culture results prior to the start of any antibiotic regimen

was recorded including the antimicrobial sensitivity

patterns.

OUTCOMES MEASURED

The outcome of interest was the determination

of the common bacterial blood isolates and antimicrobial

Fever (temperature >/=38.3C) + Neutropenia (<500 neutrophils/cu.mm.)

Low Risk High Risk

Oral IV Vancomycin not needed Vancomycin needed

Ciprofloxacin

+

Amoxicillin-

clavulanate

(adults only)

Monotherapy

Cefepime

Ceftazidime

or

Carbapenem

Two Drugs

Aminoglycoside +

Antiseudomonal

penicillin

Cefepime

Ceftazidime or

Carbapenem

Vancomycin +

Vanomycin +

Cefepime

Ceftazidime

or

Carbapenem +/-

Aminoglycoside

Reassess after 3-5 days

OBJECTIVES

General objectives:

To determine the bacterial blood isolates and

antimicrobial sensitivity pattern of pediatric cancer patients


neutropenia.

Specific objectives:

1. To determine the bacterial blood isolates of pediatric

cancer patients admitted at the Philippine General

Hospital for febrile neutropenia.

2. To determine the antimicrobial sensitivity patterns

of bacterial blood isolates of pediatric cancer patients


neutropenia.

3. To determine whether the current empiric antibiotics

given to pediatric cancer patients admitted at the

Philippine General Hospital for febrile neutropenia

are effective.

METHODOLOGY

Study Design

Retrospective, descriptive study


22

sensitivity pattern of pediatric cancer patients with febrile

neutropenia at the Philippine General Hospital.

ANALYSIS

Descriptive analysis was done on the data

collected.

RESULTS

From January 1999 to December 2003, there

were a total of 90 febrile neutropenia cases. 56% of the

subjects were male while 44% were female. 56% of the

subjects belong to the 0-6 years of age.

Table 2. Gender Distribution of Study Population

Gender N %

Male 50 62

Female 40 38

Total 90 100

Table 3. Frequency Distribution of Study Population

According to Nature of Malignancy

Nature of Malignancy N %

Hematologic 56 62

Oncologic 34 38

Total 90 100

Table 4. Frequency Distribution of Study Population According

to Blood Bacterial Isolates

Blood Bacterial Isolates N %

Streptococcus viridans 1 1

Gram-negative bacilli 1 1

Staphylococcus epidermidis 1 1

Candida sp. 1 1

Salmonella sp. 1 1

Haffnea alveii 1 1

Table 1. Age Distribution of Study Population

Age Group (Years)

0-3

4-6

7-9

10-12

13-15

16-18

>18

Total

N

25

25

3

18

16

3

0

90

%

28

28

3

20

18

3

0

100

Among the 90 subjects, 62% had hematologic

malignancy i.e. acute lymphocytic leukemia, acute

myelogenous leukemia. 38% were oncologic cases

comprising of osteosarcoma, embryonal carcinoma,

neuroectodermal sinus tumor, nasopharyngeal carcinoma,

Wilm’s tumor, Ewing’s sarcoma, rhabdomyosarcoma,

malignant mixed germ cell tumor and malignant peripheral

nerve sheath tumor.

Only 7% of the patients had growth in the blood

culture. 93% had no growth. Table 4 and 5 indicates the

blood microbial isolates and antimicrobial sensitivity

patterns of these isolates. Among the patients who had

growth in the blood culture, 50% grew Gram-negative

bacteria, 33% had Gram-positive bacteria and 17% had

fungal isolate.

All patients received Ceftazidime as empiric

antimicrobial therapy in combination with Netilmycin for

patients admitted in 1999 or Amikacin for patients

admitted from January 2000 to December 2003. Majority

patients given Ceftazidime with Netilmycin/Amikacin had

lower temperature and less febrile episodes on the third

day of antibiotics with increasing absolute neutrophil count

except for patients who developed nosocomial infections

causing delay in recovery and prompting shift of

antibiotics.


23

DISCUSSION

Bacteremia is detected in only a handful of

pediatric cancer patients with febrile neutropenia. Studies

done by Mahmud, Latiff, Celiken, Ariffin and Muller had

growth in blood culture in only 25%, 24%, 27% 35.4%

and 24% of their subjects respectively.10,8,4,2,11 This is

comparable with the blood culture results of pediatric

cancer patients with febrile neutropenia at the Philippine

General Hospital. In terms of major etiologic agents, the

trend varies per institution. Although Gram-positive

bacteria accounts for 60-70% of microbiologically

documented infections based from the IDSA data, this is

not so in other institutions. In a study done by Mahmud

among pediatric cancer patients with febrile neutropenia

in Riwalpindi 51.7% of his subjects grew Gram-positive

bacteria in their blood culture.10 This is similar to the

study done by Celkan in Istanbul, Turkey where 60% of

the isolated bacteria were coagulase-negative

Staphylococcus sp. and Staphylococcus aureus.4

63.4% of the subjects in a study done by Kern grew

coagulase-negative Staphylococcus sp.7. Gram-negative

bacteria on the other hand, was the predominating isolates

in the studies done by Latiff and another one by Ariffin

with yield of 64% and 62% respectively.8,2 While the

international trend shows that gram-positive bacteria is

the predominant isolate, the 2002 Guidelines for the Use

of Antimicrobial Agents in Neutropenic Patients with

Cancer published by IDSA still recommends the use of

broad-spectrum antibiotics that would cover for both

gram-positive and gram-negative bacteria. Hence, most

patients respond well to the empiric antibiotics given.10,

8,4,2,11

CONCLUSION

Majority of pediatric cancer patients with febrile

neutropenia yielded no growth in blood culture. However,

most cases responded well with the empiric antibiotic

combination of Ceftazidime and Amikacin. The

predominant pathogen isolated were Gram-negative

bacteria which is in contrast with the international trend.

These are also sensitive to the current antibiotic regimen.

The empiric antibiotic therapy are effective and well

tolerated in febrile neutropenia.

RECOMMENDATION

The types of microbial isolates and sensitivity

patterns should be continuously monitored to identify

trends and to gauge the suitability of antibiotics chosen

for empirical therapy. The microbiological laboratory

should also act in consultation with the clinician to

determine the optimal approach for blood cultures in the

immunocompromised patients.REFERENCES

1. Ammann RA, Hirt A, Luthy AR, et. al. Predicting bacteremia

in children with fever and chemotherapy-induced

neutropenia. Pediatric Infectious Disease Journal. 2004

January;23(1):61-7.

2. Ariffin H, Navaratnam P and Lin HP. Surveillance study of

bacteremic episodes in febrile neutropenic children.

International Journal of Clinical Practice. 2002

May;56(4):237-40.

3. Behrman RE, Kliegman RM, Jenson HB. Nelson Textbook

of Pediatrics 16th edition 2000:785-787.

S I R S I R S I R S I R S I R S I R

Ceftazidime +

Amikacin

Meropenem

Piperacillin-

Tazobactam

Ciproflo-

xacin

Netilmycin

Co-amoxy-

clav

Table 5. Sensitivity Pattern of Blood Microbial Isolates

Anti- S. G(-) S. Candida Salmo- H.

biotic viridans bacilli epider sp. sp. nella alveii

midis

+

+

+

+

+

+

+

+

4. Celkan T, Ozkan A, Apak H, et. al. Bacteremia in childhood

Cancer. Journal of Tropical Pediatrics. 2002

December;48(6):373-7.

5. Dubey AP, Singhal D and Prakash SK. Febrile episodes in

childhood malignancies. Indian Pediatrics. 2002

October;39(10):952-7.

6. Hughes WT, Armstrong D, Bodey GP, et al. 2002

Guidelines for the use of antimicrobial agents in

neutropenic patients with cancer. CID 2002;34:730-751.


24

47. Kern WV. Risk assessment and risk-based therapeutic

strategies in febrile neutropenia. Infectious Disease

2001;14:415-422.

8. Latiff Z, Zulkifli SZ and Jamal R. Risk Assessment and

microbiological profile of infections in pediatric cancer

patients with febrile neutropenia. Malays J Pathol. 2002

December;24(2):83-9.

9. Muller J., Schmidt M, Koos R, et. al. Management of

fever in immunocompromised children. Original Abstracts-

2001: abstract nr 35, 6th International Symposium on Febrile

Neutropenia. 2001.

10. Mahmud S, Ghafoor T, Badsha S, et. al.. Bacterial infections

in pediatric patients with chemotherapy induced

neutropenia. J Pak Med Assoc. 2004 May;54(5):237-43.

11. Muller J, Schimdt, Koos R, et. al. Management of fever in

immunocompromised children. Original Abstracts-2001:

abstract nr 35, 6th International Symposium on Febrile

Neutropenia. 2001

12. Rebedea I, Radu I and Davila C. Empirical therapy for

bacterial infections in neutropenic patients. Original

Abstracts-2001: abstract nr 35, 6th International Symposium

on Febrile Neutropenia. 2001


25

ABSTRACT

Objective: To determine the in vitro antimicrobial activity

of probiotic containing milk against community acquired

bacterial pathogens in the pediatric age group.

Design: Experimental Study

Methods: In vitro analysis of the antimicrobial activity

of probiotic milk in comparison to antibiotics against

control strains based on the Kirby Bauer Method of disc

susceptibility testing. Kruskall Wallis Test was used to

analyze the difference between the mean zones of

inhibition of the different control groups. Chi square and

Fisher Exact Test was used to analyze % susceptibility.

Results: Zones of inhibition of probiotic containing milk

were observed among the three bacterial pathogens

tested. The mean zones of inhibition produced by the

probiotic milk showed smaller means for Streptococcus

pneumoniae ( 9.04 +/-5.26) and H. influenzae (9.76 +/

- 7.65) as compared to their respective antibiotics:

Penicillin G (30.18+/-0.70) and Chloramphenicol (30.96

+/- 1.86) (p value <0.000001). A larger mean zone of

inhibition was produced for Staphyloccocus aureus

(16.96+/- 5.30) compared to Oxacillin (12.92+/- 0.65).

Comparison of the % susceptibility showed higher

susceptibility of Streptococcus pneumoniae to Penicillin

G and H. influenzae to Chloramphenicol when compared

to the probiotic containing milk. Staphyloccocus aureus

however, showed a better susceptibility to the probiotic

containing milk (88%) vs. Oxacillin (64%) with a P value

of 0.04.

Conclusion: Probiotic milk containing Lactobacillus and

Bifidobacteria was observed to have in vitro

antimicrobial activity against Streptococcus pneumoniae,

H. influenzae, and Staphyloccocus aureus . It has a

better antimicrobial activity against S. aureus as

demonstrated by a larger zone of inhibition and increased

proportion of disc susceptibility than Oxacillin.

Simone Rosario C. Cid, MD*, Ma. Carina Cruz, MD*, Vincent Faustino, MD*, Alexander O.

Tuazon, MD*

IN VITRO STUDY ON THE ANTIMICROBIAL ACTIVITY OF PROBIOTIC

MILK AGAINST COMMON PEDIATRIC COMMUNITY ACQUIRED RES-

PIRATORY PATHOGENS

INTRODUCTION

There has been an increasing scientific and

commercial interest in the use of beneficial

microorganisms, or probiotics for the prevention and

treatment of disease. For many years, probiotics such as

Lactobacillus and Bifidobacteria in food products have

been touted for their reputed health benefits. However,

scarcity of supporting evidence for these health effects

was, in previous years, largely anecdotal. Until recently,

evidence has started to accumulate, as studied in literature,

from good quality clinical control trials with randomized,

placebo controlled design; and deductions from well-

founded in vitro studies.

The use of probiotics to control certain infections

has, likewise, started to gain acceptance. The alarming

rise of inappropriate antibiotic use, and antimicrobial

resistance, along with renewed interest in ecological

methods to prevent infections, makes probiotics a very

interesting field for research. Latest studies to date on

their potential use in infectious disease include an in vitro

study showing comparable antimicrobial activity of

probiotic containing milk with that of breastmilk against

common bacterial isolates in a hospital setting.1 Another

double blind, randomized controlled trial in daycare centers

studied the effect of probiotic milk on diarrhea and

respiratory infections in children, and reported for the

first time reductions in respiratory infections and their

severity.2 The extent to which probiotic containing milk

is able to exert activity against common bacterial

pathogens, however, has not been studied. Because of

this new benefit, an in vitro study to investigate the

antimicrobial activity of probiotic- containing milk against

common community acquired bacterial pathogens in

children is being undertaken. A comparison of the

antimicrobial activity of the commonly used antibiotics

against these pathogens in vitro also needs to be

determined.

Keywords: probiotics, antimicrobial activity, community, acquired pathogens



26

OBJECTIVES

General Objectives

This study was undertaken to determine the in

vitro antimicrobial activity of probiotic- containing milk

against community acquired bacterial pathogens in the

pediatric age group.

Specific Objectives

1. To determine the in vitro antimicrobial activity of

probiotic-containing milk against pediatric community

acquired bacterial pathogens, namely: H. influenza,

S. pneumoniae, and S. aureus

2. Compare the in vitro antimicrobial activity of

probiotic-containing milk versus Chloramphenicol,

Penicillin G, and Oxacillin based on zones of inhibition

and on known susceptibility patterns of H. influenza,

S. pneumoniae, and S. aureus to these antimicrobials

MATERIALS AND METHODS

Samples

One commercial milk formula containing

probiotics Lactobacillus and Bifidobacteria (Gain Plus,

ABBOT Pharmaceuticals) was prepared as instructed

by its manufacturer using sterile water and containers.

Using sterile syringes, two ml of prepared milk formula

was transferred into sterile plastic petridishes ready for

use.

The pathogens used as reference bacterial

strains are control srains as follows: Haemophilus

influenzae ATCC 49247, Steptococcus pneumoniae

ATCC 41619, and Staphylococcus aureus ATCC 25922

obtained from the Microbiology and Infectious Disease

Center in Alabang

Controls

Sterile water was used as negative control. The

antibiotics Chloramphenicol, Penicillin G and Oxacillin

were used as positive control.

Preparation of the Culture Media

Standardization of the culture media and

preparation of the control strains through broth cultures

was done by a single senior medical technologist in

accordance with the National Committee for Clinical

Laboratory Standards ( NCCLS 2000). Probiotic-

containing milk and Antibiotic Susceptibility Testing

For testing susceptibility of the bacterial

pathogens, the Kirby Bauer Disk Diffusion method was

employed. 75 sterile blank 6 mm disks were dipped into

the probiotic -containing milk preparations then placed

and equally distributed on the prepared MHA culture

media streaked with the three respiratory pathogens

alongside antibiotic disks specific for a particular bacteria;

Penicillin G for S. pneumoniae, Chloramphenicol for H.

influenza , and Oxacillin for S. aureus . The same was

done for sterile water which was used as negative control.

All disks were incubated for 18-24 hours at a temperature

of 37 0C. Measurement of the zones of inhibition produced

by the probiotic-containing milk, antibiotics (positive

control), and sterile water (negative control) were done

on the 24th hour using a standard caliper of 0.05 mm.

Results were recorded and tabulated accordingly.

Outcome Measurement and Data Analysis

In vitro antimicrobial activity of probiotic

containing milk against common community acquired

bacterial pathogens was measured by zones of inhibition

1. Measurement of the mean zones of inhibition of

milk containing Lactobacilli and Bifidobacteria

2. Measurement of the mean zones of inhibition of

the negative and positive controls

3. Comparison of the mean zones of inhibition of

probiotic-containing milk and known zones of

inhibition based on standard susceptibility patterns

of antibiotics: Chloramphenicol, Pen G, and Oxacillin

against H. influenza, S. pneumoniae, and S.

aureus, respectively, was done using the Kruskal

Wallis Test and Mann Whitney U test. A p value of

<0.05 was considered statistically significant.

4. Measurement of the percentage susceptibility

defined as proportion of disks showing susceptibility

of test organisms to antibiotics an probiotic

containing milk, based on standard susceptibility

patterns of the antibiotics use for each organism

was compared using Chi-square test and Fisher

Exact Test

RESULTS

This study included one commercial milk formula

containing the probiotics Lactobacillus salivarius and

Bifidobacteria; and control strains namely, S.

pneumoniae, H. influenzae and S. aureus

The zones of inhibition produced by the probiotic-

containing milk , Penicillin G, Chloramphenicol, and

Oxacillin against the these pathogens were compared.

The zone of inhibition produced by the milk is a measure

of its activity to the reference bacteria, with a larger value

interpreted as representing a better in vitro antimicrobial

activity.

Table 1 and 2 showed a significant difference

in the mean zones of inhibition between the probiotic-

containing milk and Penicillin G (p value <0.000001).


27

For Hemophilus influenzae, the result likewise,

showed a significant difference in the mean zones of

inhibition. When compared to Chloramphenicol, the

probiotic-containing milk was noted to have a weak in

vitro antimicrobial activity against this pathogen. (Tables

3 & 4)

When the proportion of the % susceptibility was

compared between the 3 groups using Chi- square ,

significant differences were noted. Streptococcus

pneumoniae showed a 100% susceptibility to Penicillin

G, with only 8% to the probiotic containing milk. H.

influenzae showed an 87.5% susceptibility to

Chloramphenicol as against 8% with the milk tested.

Staphylococcus aureus, on the other hand, showed a

Using established standard susceptibility patterns,

zones of inhibition produced by the milk and Penicillin G

for Streptococcus were labeled as susceptible if it had a

zone of > 20mm, 29 mm for Chloramphenicol against H.

influenza, and 13 mm for Oxacillin against

Staphylococcus aureus.

For Staphylococcus aureus, comparison was

significantly different. Compared to Oxacillin, the mean

zone of inhibition produced by the probiotic containing

milk was significantly larger, hence, better antimicrobial

activity. (Table 5 & 6)

Table 3. Comparison of the Mean Zone of Inhibition for

Hemophilus influenzae

Mean +/- SD 9.76 + 7.65 6.0 + 0 30.96+ 1.86

Median 6 6 30.5

Probiotic- Sterile Chloram- P value

milk water phenicol

<0.000001 (S)

Kruskall

Wallis Test

Table 2. P Values for the Comparison of Two Groups

Variables p value

Probiotic- containing Milk

Vs

Sterile Water


Vs

Penicillin G

Penicillin G

Vs

Sterile Water

0.005

0.000001

0.000001


Streptococcus pneumoniae

Mean +/- SD 9.04 + 5.26 6.0 + 0 30.18+ 0.70

Median 6 6 30

Probiotic- Sterile Penicillin P Value

containing Water

Milk

<0.000001 (S)

Kruskall

Wallis Test



Vs

Sterile Water


Vs

Chloramphenicol

Chloramphenicol

Vs

Sterile Water

Mann Whitney U Test

Variables P Value

0.009

0.000001

0.000001


Staphylococcus aureus

Mean +/- SD 16.96 + 5.30 6.0 + 0 12.92+ 0.65

Median 15 6 30

Probiotic- Sterile Oxacillin P Value

containing Water

Milk

<0.000001 (S)

Kruskall

Wallis Test


Vs Sterile Water


Vs Oxacillin

Oxacillin

Vs Sterile Water


Variables P Value

0.00004

0.0004

0.000001


28

In ancient times, the benefit and health potential

of foods containing live bacteria have been recognized.

During the beginning of the 20th Century, Elie

Metchnikoff proposed a scientific rationale for the

beneficial effects of bacteria in yogurt and attributed long

life to intake of yogurt containing Lactobacillus species.

Since then, multiple antimicrobial properties have been

suggested.

The word ‘probiotic’ is derived fron the Greek,

‘for life’.5 Today, they are defined as live microbial food

supplements with a demonstrated effect on human health.

There are several commercially available supplements

contaning probiotics, either as fermented food products

or dairy based foods. Recently, with the advancement in

research and infant nutrition, it has been introduced in

some milk formulas and powdered milk supplements.

The main mechanisms whereby probiotics exert

protective or therapeutic effects are not fully elucidated,

but multiple mechanisms have been postulated including

lactose digestion,6 production of antimicrobial agents,7,8

competition for space nutrients, and immunomodulation:

adjuvant like effects on intestinal and systemic immunity9

and non-humoral immunity.10

In a review of recent studies, probiotic therapy

showed substantial evidence of clinical benefit in pediatric

patients with viral gastroenteritis and prevention of

nosocomial diarrhea;11 in the treatment of Clostridium

defficile diarrhea.12 The use of Lactobacillus GG was

also found to be effective in the prevention of early atopic

disease in children with high risk.13 These clinical studies

have attempted to establish the value of probiotics in the

prophylaxis and treatment of childhood diseases. Fewer

studies have been done to evaluate their role in the

prevention of community acquired infections. In one such

study, long term consumption of probiotic milk was found

to be beneficial in reducing incidence of diarrhea and

respiratory infections.

To evaluate further the probiotics’ potential in

infections, the in vitro antimicrobial activity of a probiotic

milk containing Lactobacillus and Bifidobacteria

against common bacterial respiratory pathogen was

determined. Zones of inhibition were observed in all the

three organisms tested. However, among these 3

organisms, only Staphylococcus aureus was found to be

susceptible to the probiotic containing milk with a more

superior antimicrobial activity over Oxacillin. In a similar

study comparing the same probiotic containing milk and

breastmilk, zones of inhibition were likewise larger for S.

aureus , and the observed antimicrobial activity was

comparable to breastmilk.

Table 8. P Values for the Comparison of the % Susceptibility

Between Two Groups

DISCUSSION

Increased risk of disease in the pediatric age

group has obvious public health and economic

consequences, such as direct medical costs as well as

indirect costs of parents having to take time off from

work to look after sick children.3 The successful

prevention of infections could be extremely useful for

families and for society in general. Since prevention would

obviate the need for treatment, the use of probiotic

bacteria to prevent common childhood infections have

been proposed.4

better susceptibility pattern to the probiotic containing milk

compared to Oxacillin: 88% vs. 64%. (Table 7)

Comparison of the % susceptibility between two

groups using the Fisher Exact Test showed similar results.

Moreover, the results further show that the %

susceptibility of S. aureus to probiotic containing milk is

significantly higher than Oxacillin. (p value 0.04).

Table 7. Comparison of the % Susceptibility

Probiotic Sterile Anbtibiotic p value

Containing Water

Milk

Streptococcus 2 (8.0%) 0 (0%) 25 (100%) 0.000001

pnueumoniae (Penicillin G) (Significant)

H. influenzae 2 (8.0%) 0 (0%) 7 (87.5%) 0.000001

(n=8) (Significant)

(Chloram-

phenicol)

Staphylococcus 22 (88.0%) 0 (0%) 16 (64.0%) 0.000001

Aureus (Oxacillin) (Significant)

Probiotic-

containing

Milk

Vs

Sterile Water

Probiotic-

containing

Milk

Vs

Antibiotic

Antibiotic

Vs

Sterile Water

0.49

(Not

Significant)

0.000001

(Significant)

0.000001

(Significant)

0.49

(Not

Significant)

0.00006

(Significant)

0.000001

(Significant)

0.000001

(Not

Significant)

0.04

(Significant)

0.000001

(Significant)

Streptococcus

PneumoniaeHemophilus

influenzaeStaphylococcus

aureus


29

REFERENCES

1. Torralba, R. In vitro study of the antimicrobial effect of

probiotic containing milk vs. breastmilk against 5 common

pediatric bacterial isolates at MDH. July 2001.

2. Hatakka, K, et. Al. Effect of long term consumption of a

probiotic milk on the infections in children attending day

care centers: A double blind randomized trial. BMJ

2001;322:1327-9.

3. Bell DM, Gleiter, Merces, AA. Et al. Illness associated with

child day care: A study of incidence and cost. Am J. of

Public Health. 1989; 79: 479-84.

4. Wanke, C. Do probiotics prevent childhood illnesses. BMJ

June 2001; 322: 1318-1319.

5. Alvarez- Olmos MI, Oberhelman RA. Probiotic agents and

infectious disease: A modern perspective on traditional

therapy. CID. 2001.June 1;32 (11) 1567-76.

6. Salminen, S., Bouley, MC. Functional food science and

gastrointestinal Physiology and function. BT J. Nutrition.

1998;80 ( Suppl 1) 147-71.

7. Mcfarlane G, Cummings JH. Probiotics and prebiotics: can

regulating the intestinal bacteria benefit health. BMJ

1999;318:999-1003.

8. SilvaM, Jacoubs NV, Deneke C. Gorbarch SL. Antimicrobial

substance from a human lactobacillus strain. Antimicrobial

agents Chemother 1987; 31: 1231-3.

9. Koop- Hoolihan. Prophylactic and Therapeutic Uses of

Probiotics: A Review: J Am Diet Assoc. 2001 Feb;

101(2):229-38

10. Sheih YH, Chiang BL, Wang LH, Liao, CK, Gill, HS.

Systemic Immunity- enhancing Effects in Healthy subjects

Following Dietary Consumption of Lactic acid Bacterium

Lactobacillus rhamnosus HN001. J. Am Coll Nutr.2001

Apr;20 (2 Suppl): 149-56.

11. Szajewska et al. Efficacy of Lactobacillus GG in Prevention

of Nosocomial Diarrhea in Infants. J Pediatr.200.Mar;

138(3):361-5.

12. Marteau, PR, et al.Protection from Gastrointestinal

Diseases With the use of Probiotics Am.J Clin Nutr 2001

Feb; 73(2 suppl): 430S- 436S.

13. Kolliomaki M, et al. Probiotics in the Primary Prevention of

Atopic Diseases: A randomized Placebo Controlled Trial.

Lancet 2001 Apr 7;357(9269): 1076-9.

14. Kimura S. et al. Multiple antibiotic resistant lactic acid

bacteria preparation Eliminated MRSA from the decubitus

of a bed ridden elderly patient. Clin Med J. 1997;110:157-9.

The significant antimicrobial activity of the

probiotic containing milk observed in this experimental

study may shed light on an interesting case report in

1997 which describes successful treatment of a decubitus

edcer colonized by MRSA with the use of a Lactobacillus

preparation.14 Studies of this potential use may have

profound impact in the coming years.

CONCLUSION

In conclusion, milk containing Lactobacillus and

Bifidobacteria has in vitro antimicrobial activity against

S. pneumonia and H. influenzae but less than Penicillin

amd Chloramphenicol, respectiveley. It has better

antimicrobial activity against S. aureus as demonstrated

by larger zones of inhibition and increased proportion of

disc susceptibility to than Oxacillin.

RECOMMENDATION

This experimental study has presented data

showing that probiotic containing milk has a significant

antimicrobial activity against Staphylococcus aureus.

Further research is required to delineate this potential. It

is therefore recommended that clinical in vivo studies be

done to measure this in vitro advantage, in order to

translate it to clinically relevant outcomes.


30

THE EFFECT OF TOPICAL APPLICATION OF MUPIROCIN IN

INTRAVENOUS CATHETER SITE IN THE INCIDENCE OF SUPERFICIAL

PHLEBITIS

Ronald Allan N. Geraldez, MD*, Ma. Liza M. Gonzales, MD*

ABSTRACT

Background: Superficial phlebitis is a common

complication of venoclysis although its incidence

especially in pediatric hospital setting is not often known

and evaluated. A standard aseptic technique in IV line

insertion is observed to decrease its incidence but the

use of topical antibiotic is rarely used.

Study objectives: Our objective was to determine if

topical application of antibiotic mupirocin will affect the

incidence of superficial phlebitis as compared to using

alcohol alone in the preparation of the IV insertion site.

Setting: Pediatric department wards and emergency room

of the University of the Philippines-Philippine General

Hospital.

Methodology: In a randomized control study, 69 pediatric

patients for intravenous catheter insertion were evaluated.

Thirty-six patients were assigned in the control group

whose IV insertion site were prepared with alcohol alone

while 33 patients in the case group received topical

mupirocin after application of alcohol in the IV insertion

site. The IV insertion site were than evaluated daily by

the investigator for the development of superficial phlebitis

until the IV cannula were removed.

Results: Eight out of the 36 patients (22%) in the control

group while 4 out of the 33 patients (12%) in the case

group developed phlebitis.

Conclusion: The use of topical mupirocin in the IV

insertion site prior to cannulation can decrease the

incidence of superficial phlebitis.

Background

Phlebitis in insertion site is not an uncommon

complication of peripheral intravenous catheterization with

cases reported to range from a low 2.3% to as high as

31%.1.2,3,4 It can manifest as an inflammation in the

insertion site to cellulitis and suppuration in the contiguous

areas to a more severe catheter related sepsis.

Key Words: intravenous cannulation, mupirocin, pediatrics, superficial phlebitis, topical antimicrobial

In UP-PGH pediatric wards and emergency

room, a proper and successful IV catheter insertion is

one of the most basic skill that interns and residents should

learn. This can be made difficult by the fact that

peripheral veins of pediatric patients are small and often

difficult to locate visually and by palpation. Formal IV

therapy training for hospital personnel has been shown

to decrease leakage, phlebitis and infiltration

complications of IV cannulation.5 In PGH, however, most

medical interns learn the technique by practice while

serving their rotation in the pediatrics department.

A proper and effective way of doing IV

catheterization entails an aseptic technique that every

health personnel performing the procedure should

observe. However, the incidence of phlebitis may still

occur in the insertion site requiring the removal of the IV

cannula and reinsertion of new cannula in another site.

Several factors may predispose to the

development of superficial phlebitis in IV cannulation site

foremost of which is the length of time the cannula is in

place or the dwell time. The Center for Disease Control

guidelines recommends replacement of IV catheter every

48 to 72 hours for adults but no such recommendation

for pediatric patients exists.6 Studies however has shown

that there is no significant differences between phlebitis

rate of cannula with dwell time of 72 hour and 96 hour.7,1

Thus, considering the difficulty of successful cannulation,

the limited number of skin sites, and the cost of the devise,

the cannula may be left in place for longer than 48 hours.9

Among neonates, catheter life is on the average lasts for

only 30 hours. Extravasation, erythema, accidental

displacement, and worse, phlebitis may require the

removal and reinsertion into another site of the cannula.

Without these complications however, catheter can be

safely maintained with adequate monitoring for up to 144

hours.3

It is advisable that IV cannula should be used

only once per attempt but this is not always the case in

PGH where the same cannula can be used several times*Department of Pediatrics, UP-PGH


31

in an attempt at successful cannulation. A transparent

polyurethane cannula (Insyte) is the most commonly type

of used which compared to butterfly steel cannula is

said to decrease the risk of phlebitis.10, 11, 12

A significant factor in the development of

phlebitis is the infusate or the type and frequency of

medication or fluid infused and pushed. Drug irritation is

the most reliable predictor of phlebitis.13 Total parenteral

nutrition, blood products, potassium and sodium

bicarbonate drips are just some of the infusate commonly

implicated in phlebitis.

There are commercially available IV cannula

dressings available in the market such as transparent

dressing and sterile gauze but these are more expensive

and thus has not been popularly used. The use of gauze

versus transparent dressing shows no relationship with

IV complications such as bacterial colonization and

phlebitis although a study has shown less evidence of

phlebitis with adhesive bandage compared with gauze.14,3

Bacterial colonization or the presence of positive culture

in the cannula tip is widely believed to be not correlated

with the development of phlebitis.15 There has been no

reported study comparing these commercially available

dressing with adhesive tape (Leukoplast) which is

generally what is being used in PGH.

The most practical way of preventing phlebitis is

the employment of aseptic technique in the performance

of the peripheral IV cannulation procedure. The usual

practice in this institution is to topically clean the area in

the skin with alcohol and the secure the site with

leukoplast. Application of a topical antibiotic

prophylactically in the insertion site such as mupirocin

ointment is not usually done except although occasionally,

povidone iodine, a topical antiseptic is used. Some studies,

however has shown that the use of antimicrobial ointment

has resulted in higher proportion of phlebitis.16

Mupirocin, a topical antibiotic available in

ointment form has been used in the treatment of

secondarily infected wounds. It is likewise often used in

the care of indwelling central lines to prophylactically

prevent phlebitis or even treat secondarily infected central

line site. It is effective against gram positive and gram

negative organisms including methicillin resistant

Staphylococcus aureus. As to date, there is no local

study investigating the efficacy of the application of

mupirocin in the prevention of the development of

superficial phlebitis in peripheral cannulation site.

OBJECTIVES

The primary objective is to assess whether single

topical application of mupirocin ointment in the peripheral

IV cannulation site administered prior to IV cannulation

compared to applying alcohol alone decreases the

incidence of phlebitis.

Secondary objectives include:

1. to determine and assess the factors that predisposes

to the development of superficial phlebitis namely:

a. the length of time the IV cannula is in place

b. the type of IV medications infused

c. the number of attempts before the cannula has been

inserted

d. the type of personnel (i.e. intern, resident) who

performed the cannulation

Type of Study

A randomized controlled trial in which mupirocin

ointment topically applied prior to IV cannulation is

compared with using alcohol alone.

Participants

Patients in the pediatric wards and emergency

room requiring indwelling peripheral IV cannulation for

more than 24 hours.

Exclusion Criteria

Patients whom IV cannula was removed within

24 hours from insertion.

Outcome Measures

The presence of signs of phlebitis in the area

where IV cannulation has been placed as assessed by

the investigator.

METHODOLOGY

All patients in the emergency room and wards

for intravenous catheter insertion that was referred for

inclusion in the study was randomly assigned to case

group or control group. For every patient enrolled in the

study a card was drawn from a set of cards randomly

marked with “B” and unmarked cards. Those assigned

with unmarked cards was put in the control group while

those with marked “B” was placed in the case group

The choice of IV site for each patient was at

the discretion of the physician and or intern as is the choice

of the IV catheter to be used. The insertion technique

was done percutaneously without prior skin incision. The

skin was prepared with alcohol. All patients in the case

group will have topical mupirocin applied to the area

covering at least 0.25 cm prior to IV insertion. The

insertion site would then covered with an adhesive tape.


32

The catheters were subsequently handled ac-

cording to the normal practice of the attending medical

and nursing staff. Each patient was seen daily by the

investigator and the patient was questioned about pain in

the insertion site, or/and the IV site was inspected and

palpated. The presence of phlebitis was defined as the

presence of a palpable cord or the presence of at least 2

of the following physical changes along the course of the

vein: warmth, erythema, tenderness and induration.

RESULTS

Of the 92 patients enrolled in the study, only 36

in the control group and 33 in the case group were

included in the evaluation. Twelve patients in the control

group out of 48 (25%) and 11 out of the 44 (25%)

patients in the case group were excluded because their

IV cannula were removed in less than 24 hours or the

patients were discharged before the investigator was able

to assess the IV site. Subject characteristics for both

groups were similar with respect to sex although there in

terms of age, there were more subjects in the 1 to 12

months age group among the control. For both control

and case group, the locations of the IV insertions had

almost similar distribution and most were done in the hand.

Final result had shown that 8 out of the 36 (22%) subjects

in the control group developed phlebitis as compared to

the case group in whom 4 out of the 33 (12%) subjects

had phlebitis.

A. Dwell time

The average dwell time for subjects in the control

group is 62.9 hours (SD 30.3 hours) as compared to the

case group with average dwell time of 62.8 hours (SD

30.4). If subjects whom IV cannula were electively

removed or those whom cannulation where removed

because they were no longer need for were excluded,

the average dwell time became 62.7 hours (SD 29.9) for

the control and 65 hours (SD 27.6) for the case group.

Of the total of 12 patients who had phlebitis, 5 had their

cannula in place for 24-48 hours, 3 of them for 49-72

hours, 2 for 73-96 hours while 2 had their cannula in place

for 145-168 hours.

B. Type of Infusate

Of the 12 patients in the control group who

developed phlebitis, 8 were given IV fluids while 4 had

heparin lock. Eight were given IV antibiotics while 3

were given blood products.

Table 2. Subjects in the control group who developed phlebitis

and the type of infusate given

1 D5 0.3 NaCl Mannitol,

Dexamethasone

2 D5 IMB Ampicillin, Famotidine

Metronidazole

3 D5 IMB Penicillin G, Vitamin K,

Amikacin Paracetamol

4 Meropenem

5 Piperacillin- Midazolam

Tazobactam

6 pNSS pRBC

7 D5IMB + Meropenem Famotidine

K2 + Ca200

8 D5IMB Ampicillin, Vitamin K

Amikacin

Subjects

with

phlebitis IV fluids Antibiotic Others IV meds

Type of infusate

Control Group

Control

I. Sex:

Male 19

Female 12

II. Age Group

0-<1mo 3

1-12mos 19

1-5yrs 6

6-12yrs 7

13-18yrs 1

III. IV Cannulation Site

Hand:

Right 15

Left 8

Forearm:

Right 0

Left 3

Foot:

Right 5

Left 4

Leg:

Right 0

Left 1

Scalp: 0

Mupirocin

I. Sex:

Male 20

Female 13

II. Age Group

0-<1mo 3

1-12mos 11

1-5yrs 11

6-12yrs 6

13-18yrs 2

III. IV Cannulation Site

Hand:

Right 13

Left 9

Forearm:

Right 0

Left 4

Foot:

Right 4

Left 2

Leg:

Right 0

Left 0

Scalp: 1

Subject Characteristics:

Dwell Time

24-48 hrs

49-72 hrs

73-96 hrs

97-120 hrs

121-144 hrs

145-168 hrs

# of

Subjects

16

10

4

4

1

1

+

Phlebitis

5

2

1

0

0

0

# of

Subjects

14

10

5

1

2

1

+

Phlebitis

0

1

1

0

2

0

Control Mupirocin


33

Table 2. Subjects in theMupirocin group who developed

phlebitis and the type of infusate given

C. Number of times the IV cannula were used

There could be several attempts in IV insertion

in a subject and a cannula could be used several times by

the intern or the residents before a successful cannulation.

Majority of IV insertion fortunately was successful on

first attempt. Seven out of 51 of those who developed

phlebitis had the IV cannula used only once in an attempt.

There were 2 subjects whose cannula was used 4 times

but did not developed phlebitis.

1 D5 0.3 Nacl Furosemide

2 Penicillin G

Choramphenicol

3 pNSS Cefepime

Metronidazole plt conc

4 D5 0.3 Nacl plt conc

Subjects

with

phlebitis IV fluids Antibiotic Others IV meds

Type of infusate

Mupirocin

Table 4. No of times the cannulla has been used and the inci-

dence of phlebitis

No. of

Times the

IV Cathwas

used

1

2

3

4

30

3

1

2

+ Phlebitis

5

1

1

1

# of

Subjects

21

10

2

0

2

2

0

0

Mupirocin Control

D. Type of Personnel Performing the cannulation.

In PGH pediatric wards and emergency room,

the interns were the first in line who should perform the

IV insertion, thus 70% (36/53) of the IV insertion were

performed by the interns while the rest were done by the

residents. Seven out of the 36 insertions done by the

interns developed phlebitis while 4 out of the 18 insertions

done by the residents had phlebitis.

Table 5. The type of personnel performing the IV cannulation

and the incidence of phlebitis

Type of

Personnel

Interns

Residents

# of

Subjects

24

13

+ Phlebitis

4

4

# of

Subjects+ Phlebitis

3

1

Control Mupirocin

20

13

DISCUSSION

Phlebitis is the most common complication of IV

therapy and several factors has been implicated in its

pathogenesis. Chemical factors such as irritant drugs

and physical factors such as duration of cannulation are

just few of the identified risk factors for the development

of phlebitis.

Among the 69 subjects both in the control and

mupirocin group evaluated in this study, 12 developed

phlebitis thereby giving an incidence rate of 17%. This

is within range of the incidence of phlebitis reported in

other studies which is from a low of 2.3% to a high

31%.1,2,3,4 For those in the control group, 22% (8/36)

developed phlebitis, a rate that is higher than in the case

group with 12% (4/33). With using topical topical

mupirocin the absolute risk reduction is 10% and the

relative risk reduction of 46%. The results therefore

suggests that applying topical mupirocin (Bactroban) in

the IV insertion site may the decrease the risk of phlebitis.

However, using the statistical analysis Fisher’s exact test

this finding is not statistically significant with a 2-tail p

value of 0.34781

The rationale for the use of topical antimicrobial

in the preparation of the skin for IV insertion can decrease

the bacterial load of the skin thus decreasing the

colonization in the point of entry. Topical antimicrobial is

often employed in the care of central venous catheter

but its use in percutaneous IV cannulation is not by

standards observed. Some studies even discourage the

use of antimicrobial ointment because it can result in

higher incidence of phlebitis.

The length of time that the IV cannula is in place

is traditionally believed to be directly correlated with the

incidence of phlebitis. Two subjects however whose

dwell time exceeds 144 hours did not developed phlebitis

although 2 subjects with dwell time of 121-144 hours did.

Five subjects in the control group with dwell time less

than 48 hours had phlebitis. The per day risk of phlebitis

is not evident in this study and this supports the no longer

acceptable practice of replacing IV cannula every three

days.

In this study, the IV insertion performed by

interns showed 16% (7/44) rate of phlebitis as compared

with residents who had 19% (5/26). In PGH, it is usually

the interns who were first in line to do the IV insertion

and the procedure would be referred to the residents in

cases of difficult insertion. The higher rate of phlebitis

among those done by residents can be probably explained

by their more difficult tasks of IV insertion especially

among chronic patients.

# of

Subjects

+

Phlebitis


34

Since IV cannula is sometimes used several times

in an insertion, the number of times the cannula has been

used before a successful cannulation has been recorded

and analyzed as a risk factor of phlebitis. Although

majority of the insertion has been successful on 1st

attempt, 14% (7/51) has developed phlebitis while 23%,

(3/13), 50% (1/2) and 50%(1/2) has developed phlebitis

when the cannula has been reinserted twice, thrice and

four times respectively. It is therefore recommended

that the IV cannula be used only once and be discarded

if attempt is unsuccessful. The cost of IV cannula will

however make this suggestion impractical.

These results lead to the question of whether

there is a direct relationship between difficulty of insertion

as evaluated subjectively by those performing the IV

cannulation and by the number of attempts before a

successful cannulation has been made. A similar study

with such an objective is therefore recommended.

The type of infusate such as irritant IV medication

is a significant factor in the development of phlebitis.

Among subjects who developed phlebitis, some of the

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drugs that has been infused and recognized to be often

implicated in the development of phlebitis has been IV

fluids with KCl and Ca gluconate incorporation and blood

products packe RBC and platelet concentrate. There is

however particular classification of infusate as to their

abiltity and degree to irritate the veins and cause phlebitis.

The application of topical mupirocin may not decrease

the incidence of chemical phlebitis or those caused by

irritant infusate in contrast to those with infectious etiology

although both factors may co-exist in the development

of phlebitis.

The potential of topical mupirocin in decreasing

the incidence of phlebitis therefore needs further

confirmation. The amount of ointment used per

cannulation is so small that it will not greatly increase the

cost of IV therapy. The only problem however is the

more tedious way of inserting the cannula since the skin

site can have more glare from the shiny ointment once

applied as reported by the residents and interns who

participated in the study. However, if proven by further

studies and by evidenced based medicine, the decreased

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9. Garland, Dunne, Havens, Hintermeyer, Bozzette, Wincek,

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12. Maki, Ringer. Risk factors for infusion-related phlebitis

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13. Catney, Hillis, Wakefield, Simpson, Domino, Keller,

Connely, White, Price, Wagner. Relationship between

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2001 Sep-Oct; 24(5): 332-41

14. Pettit, Kraus. The use of gauze versus transparent

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Clin North Am 1995 Sep; 30 (3): 495-506

15. Righter, Bischop, Hill. Infection and peripheral venous

catheterization. Diagn Microbiol Infect Dis 1983 Jun; 1

(2); 89-93.


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16. Vost, Longstaff.. Infection control and related issues in

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19. Harris, Alford, Dan, Savage. Bacteremia related to IV

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21. Hoffmann, Weber, Samsa, Rutala. Transparent

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22. Hoffmann, Western, Kaiser, Wenzel, Groschel. Bacterial

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23. McKee, Shell, Warren, Campbell. Complications of

intravenous therapy: a randomized prospective study –

Vialon vs. Teflon. J Intraven Nurs 1989 Sep-Oct; 12(5):

288-95

24. Meylan. Increased risk of bacterial colonization of

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polyurethane bandages, compared to classical gauze

bandages. Schweiz Med Wocheenschr 1987 Dec 12; 117

25. Monreal, Quilez, Rey-Joly, Rodriguez, Sopena, Neira, Roca.

Infusion phlebitis in patients with acute pneumonia. Chest

1999; 115: 1576-80

26. Nelson, Garland. The natural history of Teflon catheter-

associated phlebitis in children. Am J Dis Child 1987 Oct;

141 (10): 1090-2

27. Parras, Ena, Bouza,Guerrero, Moreno, Galvez, Cercenado.

Impact of an educational program for the prevention of

colonization of intravascular catheters. Infect Control

Hosp Epidemiol 1994 Apr; 15 (4 Pt 1): 239-42.

28. Tomford, Hershey, McLaren, Porte, Cohen. Intravenous

therapy team and peripheral venous catheterassociate

complications. A prospective controlled study. Arch

Intern Med 1984 Jun; 1444(6): 1191-4

29. VandenBosch, Cooch, Treston-Aurand. Research

utilization: adhesive bandage dressing regimen for

peripheral venous catheters.Am J Infect Control 1997

Dec;25(6): 513-9


36

ABSTRACT

Objective: To evaluate the neonatal and maternal clinical

manifestations and their hematological parameters,

individually and in combination, as parameters which can

be used to formulate a scoring system in determining

neonatal sepsis.

Design: A cross-sectional study conducted at the

Neonatal Intensive Care Unit of a tertiary care teaching

hospital.

Methods: The study consisted of 100 neonates admitted

at Neonatal Intensive Care Unit at the UP-PGH Medical

Center who were clinically suspected of sepsis at birth

and within 24 hours of life. A perinatal history, clinical

profile, symptoms and laboratory data were recorded in

each case. The neonatal hematological parameters

included were total leukocyte count, total neutrophil count,

lymphocytes, immature cells, immature to total leukocyte

ratio, immature to mature cells ratio, nucleated red blood

cells, lymphocytes, absolute neutrophil count, platelet

count, and toxic granules. The maternal hematological

parameters consisted of total leukocyte count, total

neutrophil count, lymphocytes and platelet count. These

parameters were evaluated based on the standard

reference values. A blood culture was the standard

indicator for proven sepsis.

Results: There were 17 out of 100 neonates (17%)

who had culture proven sepsis and they were

predominantly preterm. Among the different parameters,

the preterm infants, neonatal platelet count and maternal

total leukocyte count were significantly associated with

neonatal sepsis with p value of 0.047, 0.02, and 0.006

respectively. Based on these factors, a scoring system

was devised to predict the probability of sepsis. A score

of 3 had a 100% sensitivity and 91.3% specificity.

Conclusion: A scoring system for predicting neonatal

sepsis could be obtained by correlating the clinical

manifestations of the neonate and the mother together

with their hematological parameters.

CLINICAL CORRELATION OF NEONATAL AND MATERNAL

HEMATOLOGICAL PARAMETERS AS PREDICTORS OF NEONATAL

SEPSIS

*Department of Pediatrics, UP-PGHKeywords: Neonatal sepsis, hematological parameters, scoring system, new-

born, perinatal infection

Willa Antoniette B. Mayuga, MD*, Pura Flor D. Isleta, MD*

INTRODUCTION

Sepsis neonatorum is used to describe the

systemic response to infection in newborn infants. It

continues to be the major cause of morbidity and mortality

in the newborn.1 Neonatal sepsis occurs in 1 to 8 cases

of all live births.2 In the Philippines, the incidence is

estimated between 4 to 9 cases per 1000 live births.3 In

the Neonatal Intensive Care Unit of the University of

the Philippines – Philippine General Hospital, it is

estimated between 2 to 7 cases per 1000 live births with

an average sepsis rate of 7%.4

Neonatal sepsis is categorized as early or late

onset. Eighty-five percent of newborns with early onset

of infection present within 24 hours, 5% present at 24-

48 hours, and a smaller percentage of patients present

between 48 hours and 6 days of life.5 The susceptibility

of the newborn is related to immaturity of both the cellular

and humoral immune systems at birth. This feature is

particularly evident in preterm neonate. Early-onset

sepsis syndrome is also associated with acquisition of

microorganisms from the mother through blood-borne

transplacental infection of the fetus, ascending infection,

and infection upon passage through an infected birth canal

or exposure to infected blood at delivery.6 Late-onset

sepsis syndrome occurs at 7-90 days of life and is

acquired from the care-giving environment.

The early signs of sepsis in the newborn are

nonspecific. Therefore, many newborns undergo

diagnostic studies and the initiation of treatment before

the diagnosis has been determined. The definitive

diagnosis of septicemia is made by a positive blood

culture.1 The incidence of culture proven sepsis is

approximately 2 in 1000 live births. Of the 7-13% of

neonates who are evaluated for sepsis, only 3-8% have

culture proven sepsis. The mortality rate of untreated

sepsis can be as high as 50%.5 Thus, most clinicians

believe that the hazard of untreated sepsis is too great to

wait for confirmation by positive cultures. They initiate

treatment while awaiting culture results.


37

However, due to the high cost of antibiotics,

inavailability of blood cultures in some community

hospitals, and the time it takes for the blood culture result

to come out, several studies have examined the laboratory

findings associated with sepsis. There is a lack of

consensus on the essential test that would identify

neonates with acute infection. In a systematic review to

determine the value of diagnostic tests for bacterial

infection in early life, it was reported that the accuracy

of tests varies enormously and the tests are of limited

value in the diagnosis of infection.7 In another study, a

combination of hematological and biochemical tests (eg.

acridine orange leukocyte cytospin test, nitroblue

tetrazolium and C-reactive protein) may provide a more

rapid and accurate diagnosis of bacteremia than

conventional microbiological methods.8 In recent years,

various investigators have evaluated some highly sensitive

and specific inflammatory markers (eg. C-reactive protein,

interleukin-6, interleukin-8, plasma elastase) to diagnose

neonatal sepsis and shock. Although these markers are

sensitive and specific, they require sophisticated and

expensive kits and are therefore impractical for routine

clinical work-up in a community health delivery systems,

particularly in developing countries.1

The use of hematological parameters for

determining sepsis was evaluated in different studies.

There was significant heterogenicity across these studies.9

The possible sources were population, age, subjects,

methodological quality, different leukocyte indices,

different cut-offs and interpretation of test results by

different laboratory observers. However, these

parameters remain to be rapid, economical, feasible,

practically possible in all laboratories and most especially,

these hematological parameters can be used as a tool in

screening neonates with sepsis1 which in turn may

decrease the antibiotic usage.10

GENERAL OBJECTIVE

This study is designed to evaluate the neonatal

and maternal clinical manifestations and their

hematological parameters, individually and in combination,

as parameters which can be used to formulate a scoring

system in predicting the probability of neonatal sepsis.

SPECIFIC OBJECTIVES

1. To provide a rapid identification of sepsis based on

complete blood count and peripheral blood smear in

correlation with clinical symptoms

2. To compare neonates who are more prone to

infection based on gestational age, weight, sex and

manner of delivery

3. To determine whether the newborn and maternal

symptoms correlate well with neonatal sepsis

4. To determine which of the newborn hematological

parameters, namely: the white blood count (WBC)

or total leukocyte count (TLC), total neutrophil count

(TNC), lymphocytes, immature cells, immature to

total neutrophil cells (I/T) ratio, immature to mature

cells (I/M) ratio, absolute neutrophil count, nucleated

red blood cells (NRBC), platelet count and toxic

granulation, are significant in predicting sepsis

4. To determine whether the maternal white blood count,

different count, and platelet count are also significant

in predicting sepsis

STUDY DESIGN

This is a cross-sectional study conducted at the

Neonatal Intensive Care Unit of a tertiary care teaching

hospital.

METHODS

Subjects

The study consisted of 100 neonates admitted at

Neonatal Intensive Care Unit (NICU) at the Philippine

General Hospital from July to September 2003 who were

clinically suspected of sepsis at birth and within 24 hours

of life or had maternal history of infection.

Inclusion Criteria:

Neonates with respiratory distress syndrome,

cyanosis, apnea, transient tachypnea, meconium

aspiration syndrome, pneumonia, low Apgar score, birth

asphyxia, lethargy, temperature instability, and

hypoglycemia.

Neonates with maternal history of infection such

as upper respiratory tract infection, pneumonia, urinary

tract infection, vaginitis, premature rupture of membrane,

chorioamnionitis, with or without antibiotic intake during

pregnancy.

Newborn with gestational age of 30 weeks and

above by pediatric aging and with a weight of more than

or equal to 1000 grams.

Study Procedure

Each neonate was examined by a pediatric

resident rotating in NICU or neonatology fellow who

recorded the signs and symptoms of the neonate,

predisposing perinatal factors and the clinical assessment

of the neonate.

Initial tests performed were complete blood count,

peripheral smear and blood culture. Blood samples (2

ml) were collected from the umbilical cord, peripheral


38

venous or arterial puncture within 24 hours of admission

before initiation of antibiotic therapy.

A 0.5-1 ml of blood sample was anticoagulated

with ethylene diamine tetra acetic acid. The total

leukocyte count and platelet count were measured on a

Coulter STKS. White blood cells were corrected for

nucleated red blood cells. Peripheral blood smears were

drawn on clean slides and stained by Wright’s stain. A

differential leukocyte count was done to obtain the total

neutrophil count (TNC), immature neutrophil count (IM),

including bands and stabs; and mature neutrophil count

(M). Neutrophils were classified as band forms when

there were no nuclear segmentation or when the width

of the nucleus at any constriction was not less than one

third the width at its widest portion. Band forms together

with less mature cell form were classified as immature

polymorphonuclear (PMN) leukocytes. Using these

values, I/M and I/T ratios were computed. One hundred

neutrophils were further examined for degenerative

changes such as toxic granulation, Dohle bodies, and

vacuolization. Toxic granulation was graded as 0 or (-)

which indicated normal granulation or no toxic granules

seen, (+) slight, (++) approximately 50% of neutrophils

contained dark granules, (+++) very high granulation in

most cells, and (++++) gross toxic granulation with the

nucleus obscured by toxic granules.11

One milliliter of blood was inoculated aseptically

into 20ml of brain heart infusion broth for culture and

sensitivity. Newborn infants with positive blood cultures

were considered to have proven sepsis while the others

were still considered as clinically suspected of infection.

The clinical manifestations and hematological

parameters were compared, individually and in

combination, with the blood culture result.

Statistical analysis

Data were analyzed by using T-test to compare

two groups with numerical data, Chi-square test to

compare or associate nominal data and Fisher Exact test

when the expected frequencies are less than 5. A level

of 0.05 was considered statistically significant. The

reference values of the neonatal hematological

parameters of Manroe, et al were used as the standard

values.12 The maternal reference values used were taken

from the values for pregnancy.13-14 The results that were

statistically significant in this study were used to design a

hematologic scoring system that will predict the probability

of sepsis.

RESULTS

Neonatal profile and neonatal sepsis

There were 17 neonates who had culture proven

sepsis which had a prevalence of 17%. Eleven of the 17

neonates were preterm (64.7%) and 6 were full term

neonates (35.3%). There was a significant correlation

between preterm and positive blood culture with p value

of 0.047. The neonatal profile showed that 12 males

(70.6%), 11 appropriate for gestational age (64.7%) with

mean birth weight of 2000 grams and 11 infants delivered

via caesarian section (64.7%) had culture proven sepsis.

However, these data were not significant (Table 1).

Table 1: Association of neonatal profile with neonatal sepsis

Patient’s

Profile

Pre-term

Full-term

Sex

Male

Female

Weight(gm)

Mean +/-

SD

Range

Weight for

pediatric

age

AGA

LGA

SGA

Manner of

Delivery

LSCS

OFE

SVD

Blood CS (+)

(n=17)

11 (64.7%)

6 (35.3%)

12 (70.6%)

5 (29.4%)

2012+/-920.7

1000 – 3800

11 (64.7%)

2 (11.8%)

4 (23.5%)

11 (64.7%)

0 (0%)

6 (35.3%)

Blood CS (-)

(n=83)

32 (38.6%)

51 (61.4%)

50 (60.2%)

33 (39.8%)

2289+/-768.6

1000 – 3900

63 (75.9%)

1 (1.2%)

19 (22.9%)

41 (49.4%)

7 ( 8.4%)

35 (42.2%)

Total

43

57

62

38

74

3

23

52

7

41

p value

0.047 (S)

(chi-square test)

> 0.05 (NS)

(chi-square test)

> 0.05 (NS)

(t-test)

> 0.05 (NS)

> 0.05 (NS)

> 0.05 (NS)

(Fisher test)

> 0.05 (NS)

(chi-square test)

The bacterial species isolated showed that 14 of the 17

(82.3%) blood culture isolates were Alkaligenes faecalis

followed by Acinetobacter (n=1), Diphteroides (n=1) and

Staphylococcus epidermidis (n=1).

Clinical profile and neonatal sepsis

Majority of the clinical manifestations of the

newborns who were suspected with sepsis had

concomitant respiratory diseases (n=77) and only 23

patients had primary impression of sepsis clinically or

based on the maternal history of infection. Among the

neonates with culture proven sepsis, there were 12

neonates who had respiratory problems (70.6%).


39

There were 13 out of the 67 mothers who had

illnesses during pregnancy with culture proven sepsis as

shown in Table 2. The maternal illnesses were upper

respiratory tract infection, urinary tract infection, and

premature rupture of membrane.

It was also noted that there were no significant

difference in the Apgar scores, neonatal symptoms

and maternal illnesses.

Table 2: Association of the neonatal clinical symptoms and

maternal symptoms with Neonatal Sepsis

Neonatal hematological parameters and neonatal

sepsis

The details of the neonatal hematological

parameters are shown in Table 3. The mean total

leukocyte count of the neonates with sepsis was

significantly lower than those without sepsis (p=0.03).

However, when compared to the reference values, there

was no significant difference. It could be noted that there

were 14 neonates with sepsis (82.4%) whose total

leukocyte count were within the normal range. The

nucleated red blood cells, total neutrophil count or

segmenters, lymphocytes, immature cells, I/T ratio, I/M

ratio, absolute neutrophil count and toxic granules were

not statistically significant. It was only the platelet count

which was significant (p=0.02) when compared to the

reference value.

Clinical profile

Apgar score at

1-min

1 – 3

4 – 6

7 – 9

Mean

Apgar score at

5-mins

3

4 – 6

7 – 9

10

Mean

Neonatal

Symptoms

Rule out Sepsis

HMD

TTN

Pneumonia

MAS

Maternal

Symptoms

(+)

(-)

4 (23.5%)

4 (23.5%)

9 (52.9%)

6

1 (5.9%)

4 (23.5%)

12 (70.6%)

0

8

5 (29.4%)

6 (35.3%)

1 (5.9%)

3 (17.6%)

2 (11.8%)

13 (76.5%)

4 (23.5%)

Blood CS (+)

(n=17)

14 (16.9%)

18 (21.7%)

51 (61.4)%6

1 (1.2%)

9 (10.8%)

71 (85.5%)

2 (2.4%)

8

18

(21.7%)14

(16.9%)20

(24.1%)17

(20.4%)14

(16.9%)

54 (65.0%)29

(35.0%)

Blood CS (-)

(n=83)

18

22

60

2

13

83

2

23

20

21

20

16

67

33

Total

> 0.05 (NS)

> 0.05 (NS)

> 0.05 (NS)

(chi-square

test)

> 0.05 (NS)

(chi-square

test)

p value

TLC (x109//L)

< 5 or >25 3 (17.6%) 13 (15.7%) 16 >0.05 (NS)

Normal 4.50-41.90 70 (8 4.03 84 (Fisher test)

14(82.4%) 15.6

TLC (x109//L)

Mean +/- SD 6.29 +/- 7.54 9.17 +/ 0.05 (NS)

-6.34 (t-test)

Range 1.02-32.85 0.48-28.56

Median 3.50 8.10

TNC(x109/L) 16 (94.1%) 81 (97.6%) 97 >0.05 (NS)

<0.78 or 1.45

Normal 1 (5.9%) 2 (2.4%) 3 (Fisher test)

Lymphocytes

(x109/L)

Mean+/-SD 4.17+/-2.75 5.60+/-3.17

Range 1.08-12.32 0.18-16.71 0.05 (NS)

Median 4.04 4.85 (test)

Immature<0.05

or >1.45

Normal16 (94.1%)

1 (5.9%)

73 (88%)

10 (12%)

89

11

> 0.05

(NS)

(Fisher

test)

Immature

Mean +/-

SD

Range

Median

0.64 +/

- 1.26

0 – 4.45

0

0.52 +/

- 1.22

0 – 6.97

0

> 0.05

(NS)

(t-test)

Table 3: Association of the Neonatal Hematological

Parameters with Neonatal Sepsis

Blood CS (+)

(n=17)

Blood CS (-)

(n=83)

Total p valueHematological

parameters

NRBC

Mean +/- SD

Range

Median

25.24 +/

- 44.81

0 – 146

2

5.46 +/

- 13.54

0 – 85

2

0.05 (NS)

(t-test)

NRBC

0 7(41.2%) 39 (47.0%) 46 >0.05 (NS)

>0 10 (58.8%) 44 (53.0%) 54 (chi-square

TLC (x109//L)

Mean +/- SD 12.14 +/- 16.66 +/ 0.03 (S)

8.68 -7.78

Range 4.50-41.90 1.70 – 41.00

Median 10.2 15.6


40

Table 3: Association of the Neonatal Hematological

Parameters with Neonatal Sepsis (cont’d)

Maternal hematological parameters and neonatal

sepsis

The obtained results of the maternal total

leukocyte count showed no significant difference but

when compared to the reference value for pregnant

women12, the results were significant. There were

94.1% mothers who had leukocytosis in the confirmed

sepsis group with p value of 0.006. The other

hematological parameters namely segmenter, lymphocyte

and platelet count had no statistical significance (Table

4).

Table 4: Association of the Maternal Hematological

parameters with Neonatal Sepsis

WBC (x109/L)

Mean +/- SD

Range

Median

WBC (x109/L)

>12

≤12

Segmenter

(x109/L)

Mean +/- SD

Range

Median

Segmenter

(x109/L)

1.8 – 7

<1.8 – >7

Lymphocyte

(x109/L)

Mean +/- SD

Range

Median

Lymphocyte

(x109/L)

1 – 4.8

< 1 - > 4.8

Platelet count

(x109/L)

Mean +/- SD

Range

Median

Platelet count

(x109/L)

150 - 400

< 150 - > 400

Maternal Blood CS(+) Blood CS(-) Total p-value

parameters (n=17) (n=83)

> 0.05 (NS)

(t-test)

0.006 (S)

(chi-square

test)

> 0.05 (NS)

(t-test)

> 0.05 (NS)

(Fisher-

test)

> 0.05 (NS)

(t-test)

> 0.05 (NS)

(Fisher-

test)

> 0.05 (NS)

(t-test)

> 0.05 (NS)

(Fisher-

test)

14.29 +/- 5.18

5.9 – 30.4

13.20

49 (59.0%)

34 (41.0%)

11.01 +/-4.76

7.87 – 25.84

10.19

1 (1.2%)

82 (98.8%)

2.18 +/- 1.13

2.33 – 7.44

1.97

75 (90.4%)

8 (9.6%)

292.5 +/- 101.5

69 – 677

277

1 (1.2%)

82 (98.8%)

15.47+/-3.61

9.3–23.19

15.30

16 (94.1%)

1(5.9%)

12.53+/- 3.89

6.70–21.24

12.71

1 (5.9%)

16 (94.1%)

1.85 +/- 0.9

0.88–3.84

1.71

16 (94.1%)

1 (5.9%)

335.7+/- 97.3

135 – 467

336

0 (0%)

17 (100%)

65

35

2

98

1

99

I/M

> 0.3 3 (17.6%) 7 (8.4%) 10 >0.05 (NS)

< 0.3 14 (82.4%) 76 (91.6%) 90 (Fisher test)

ANC

Mean +/- SD 7164 +/ 9788 +/ 0.05 (NS)

-7291 -6745 (t-test)

Range 1620-32500 582 -34850

Median 5044 8959

Platelet count

(x109/L)

Mean+/-SD 200.5+/ 243.4 +/

-108.8 -85.4

Range 54-375 55-456 0.05 (NS)

Median 203.50 243.00 (test)

Platelet count

(x109/L)

Mean+/-SD 6 (35.3%) 9 (10.8%) 15 0.02 (S)

< 150 6 (35.3%) 55-456 85 (Fisher

> 150 11 (64.7%) 74 (89.2%) test)

Toxic granules

(+) 6(35.3% 30 (36.1%) 36 >0.05 (NS)

(-) 11 (64.7%) 53 (63.9%) 64 (chi-square

test)

Toxic

granules

> 3 + < 3

Normal

0 (0%)

17 (100%)

0 (0%)

83 (100%)

Blood CS (+)

(n=17)

Blood CS (-)

(n=83)

Total p valueHematological

parameters

I/T

Mean +/- SD

Range

Median

0.108 +/

- 0.197

0 – 0.640

0

0.063 +/

-0.131

0 –0.784

2

0.05 (NS)

(t-test)

I/T

>0.16 4(23.5%) 13 (15.7%) 17 >0.05 (NS)

<0.16 10 (58.8%) 44 (53.0%) 83 (Fisher-

square test)

I/M

Mean +/- SD 0.216+/ 0.074 +/ 0.05 (NS)

-0.473 -0.159 (t-test)

Range 0-1.790 0 – 0.750

Median 0 0

0

100 NA


41

The factors which showed statistical significance

were preterm neonates, neonatal platelet count and ma-

ternal total leukocyte count. In table 5, the odds ratio of

having a positive blood culture result was 3 times (OR =

2.92) higher for preterm as compared to full term neo-

nates. The odds ratio for neonates with low platelet count

was 5 times (OR = 4.74) higher than the neonates whose

platelet count was within normal range. Lastly, for neo-

nates whose maternal total leukocyte count (TLC) was

>12, the odds ratio was 11 times higher for neonatal sep-

sis as compared to patients whose maternal TLC was

≤12. Among these factors, the maternal total leukocyte

count had the highest sensitivity of 94.1% and negative

predictive values of 97.1% (Table 6).

A scoring system was devised based on the

significant factors that were obtained in this study. There

is a significant difference in the median scores of the

patients with positive blood culture and negative blood

culture. Higher median scores were noted among the

neonates with positive blood culture (Table 7).

Since the median scores were significantly

different, each score was then computed for its individual

accuracy of determining sepsis. A score of 3 was both

highly sensitive and specific for neonatal sepsis. The

chance of getting a positive blood culture given all the 3

factors was 100%. While, if the factor were absent, the

chance of a negative blood culture was 91.3% (Table 8).

Table 8: Sensitivity, Specificity of Score Associated with

Neonatal Sepsis

Scores Sensitivity Specificity PPV NPV

1 100 35.0 11.4 100

2 100 50.0 30.0 100

3 100 91.3 60.0 100

DISCUSSION

A high index of suspicion is important in the

diagnosis and treatment of neonatal infection because it

is hampered by vague, nonspecific or nonexistent clinical

manifestation. Thus, it is difficult to establish a diagnosis

based on clinical picture alone. However, it is imperative

that treatment is instituted early because of the high

mortality associated with the neonatal infection.

In this study, there was 17% culture proven

neonates with sepsis which were predominantly preterm

(64.7%) and males (70.6%). This was possibly due to

impaired defense mechanisms and low immunoglobulin

G levels in males and low birth weight neonates.15 In

addition, newborns particularly the preterm, have less

effective phagocytosis and chemotactic activity.

Therefore, rapid invasion of offending organism occur

very fast. They also have relative immunoglobulin M

deficiency rendering them more vulnerable to gram

negative infections.16

Infections occurring at less than 72 hours of age

usually are caused by bacteria acquired in utero or during

delivery, whereas infection after that time most likely have

been acquired after birth.13 Thus, it is essential to know

the maternal illnesses which can predispose to neonatal

sepsis. These are prolonged rupture of membranes, foul

smelling amniotic fluid, maternal fever or other symptoms

suggestive of infection, unexplained fetal distress and

previous septic infant. It was noted that there were 76.5%

neonates with culture proven sepsis who had maternal

history of infection. However, the result showed no

significant difference which could be attributed to prior

antibiotic intake of the mothers during the time of illness.

The most common presenting symptom in the

early onset of sepsis is respiratory distress. It is

Scores Bld CS (+)(n=17) Bld CS (-)(n=83) Total

0 0 (0%) 21 (100%) 21

1 5 (11%) 39 (89%) 44

2 9 (30%) 21 (70%) 30

3 3 (60%) 2 (40%) 5

Table 7: Scoring

p <0.001 (S)

Table 6: Sensitivity, Specificity of Factors Associated with

Neonatal Sepsis

Factors Sensitivity Specificity PPV NPV

Preterm 64.7 60.2 25.0 89.3

Neonatal Platelet

count (<150) 35.3 89.2 40.0 87.1

Maternal

TLC (>12) 94.1 41.0 24.6 97.1

Correlation of neonatal and maternal factors with

neonatl sepsis

Factors OR 95% CI p value

Preterm 2.92 0.88 – 9.98 < 0.05

Neonatal

Platelet count 4.74 1.16 – 19.65 < 0.05

(<150)

Maternal TLC (>12) 11.1 1.42 – 87.73 < 0.01

Table 5: Factors Associated with Neonatal Sepsis


42

manifested most commonly on the first day of life, with

majority of cases at less than 12 hours.6 This was evident

in this study wherein there were 77 out of the 100

neonates (77%) presented with respiratory problems.

Other clinical signs of bacteremia include unexplained

low Apgar scores, poor perfusion, hypotension,

bradycardia, and unstable temperature.

Because of the low positivity of blood culture, its

inavailability in some peripheral health centers and the

time allotted for the result to be obtained, the need for

other tests in diagnosing neonatal septicemia is

warranted.1

The complete blood count with differential is

widely used, either singly or in conjunction with other

test or clinical findings, as a diagnostic tool for neonatal

sepsis. 17

The criteria of Manroe with 2 of 3 indices (total

PMN count, immature PMN count, and I/T ratio)

abnormal were the most reliable of the published criteria

evaluated and would have identified all infants with sepsis

and all infants with probable sepsis.12,17

In this study, there were more hematological

parameters of the neonates studied. These were total

leukocyte count, total neutrophil count, immature cells,

immature to total neutrophil cells (I/T) ratio, immature to

mature cells (I/M) ratio, platelet count and toxic

granulation. Nucleated red blood cells, lymphocytes and

absolute neutrophil count were also included because

there were no studies done yet in determining its

association with sepsis. Moreover, maternal infection

was noted to be one of the major risk factors in early

neonatal sepsis which could be documented by a complete

blood count. Thus, the maternal hematological

parameters, consisting of total leukocyte count, total

neutrophilic count, lymphocytes and platelet count, were

also used as indices in predicting neonatal sepsis.

In the neonatal hematological parameter, only the platelet

count was significant with p value of 0.02.

Thrombocytopenia was seen frequently in sepsis

proven group. This could result from increased platelet

destruction, sequestration secondary to infections, failure

in platelet production due to decreased number of

megarkaryocytes or damaging effects of endotoxin on

the platelets.11

Total leukocyte count, total neutrophilic count and

immature cells showed no significant association with

sepsis. In a study by Akenzua, it was stated that total

neutrophil count was of limited value for the diagnosis of

infection since elevation is often late and inconsistent. In

addition, newborn infants with proven bacterial infection

had normal neutrophil count but the bands increased

beyond the normal range.18 In another study, although

neutropenia in the newborn is most often secondary to

infection, there are many causes of neutropenia including

isoimmune neutropenia, congenital neutropenia, and

neutropenia due to inborn error of metabolism.19 Lastly,

neutrophilia in the absence of an increase in band may

occur in patients with no evidence of infection,

presumably the result stress or other non specific causes.

Therefore, neutrophilia itself is not a reliable or sensitive

test of infection.11

Neutrophil ratios were often abnormal during

neonatal sepsis. However, this was not evident in this

study possibly because of the variation in interpretation

of peripheral smears by different observers.

Toxic granules also showed no significant

difference in this study. The presence of toxic granules

represents the production of unusual neutrophils during

the stress leucopoiesis and infection. It is invariably

present during sepsis, a change never seen in healthy

newborn infants but are not always increased in infection. 11

The other parameters, namely: nucleated red blood cells,

lymphocytes and absolute neutrophilic count, were not

statistically significant.

The maternal hematological parameter which

showed significant correlation between sepsis was total

leukocyte count with a negative predictive value of

97.1%. The leukocyte count usually ranges from 5,000

to 12,000 x 109/L. During labor and the early puerperium,

it may be markedly elevated. The cause is not known

but probably represents the reappearance in the

circulation of leukocytes previously shunted out of the

active circulation. During pregnancy, there is neutrophilia

that consists of mature forms.13

In this study, there were 3 parameters, namely:

preterm neonates, neonatal platelet count of <150 x 109/

L, and maternal total leukocyte count of > 12,000 x 109/

L that were statistically significant. Based on these

factors, a scoring system was formulated which could

be used in determining the presence of sepsis. The

presence of one factor corresponded to a score of 1 which

indicated a positive predictive value of 11% and a score

of 2 indicated 30% positive predictive value. The

probability of getting a positive blood culture increases

with an increasing score. The highest score was 3 with

100% sensitivity and 91.3% specificity for predicting

neonatal sepsis.

It could be noted that in this study, there were

different parameters used for predicting sepsis compared

to other hematological scoring sytem.12 This was because


43

the said parameters were the ones found to be statistically

significant. The difference in the sensitivity of

hematological values to other studies could be due to wide

range of the subjects and some degree of observer

variability in reporting the peripheral smear.

CONCLUSION

Neonatal sepsis, especially in its early stages, may

be difficult to diagnose because of its nonspecific clinical

symptoms. Because the prognosis for sepsis largely

depends on early identification and treatment, these

neonates are subjected to extensive diagnostic evaluation

and empiric treatment.

The usefulness of a scoring system based on the

clinical manifestations of the neonate and mother

supported by their hematological parameters can provide

information in determining the probability of sepsis in

Pediatric Diagnosis and Treatment, 14th edition. Hay WW,

Hayward AR, Levin MJ, Sondheimer JM: editors. New

Jersey: Appleton and Lange, 1999.

7. Fowlie PW, Schimdt B. Diagnostic tests for bacterial

infection from birth to 90 days- a systematic review.

Archives of the Diseases in Child Fetal Neonatal Edition.

1998; 79: 92-98.

8. Kite P, Millar MR, Gorham P, Congdon P. Comparison of

five tests used in diagnosis of neonatal bacteremia.

Archives of Disease in Childhood. 1988, 63: 639-643.

9. Da Silva O, Ahisson A, Kenyon C. Accuracy of leukocyte

indices and C-reactive protein for the diagnosis of neonatal

sepsis: a critical review. Pediatric Infectious Diseases

Journal. 1995; 14: 362-366.

10. Philip AG. Decreased use of antibiotics using a neonatal

sepsis screening technique. The Journal of Pediatrics.

1981, 98(5): 795-799.

11. Zipursky A, Palko RT, Milner MIS, and Akenzua MB.

The Hematology of Bacterial Infections in Premature

Infants. Pediatrics. 1976, 57(6): 839-853.

12. Manroe BL, Weinberg AG, Rosenfeld CR, Browne R. The

neonatal blood count in health and disease. The Journal

of Pediatrics. 1979, 95(1): 89-98.

13. Cunningham FG, Grant N. Maternal Adaptations to

Pregnancy. Williams Obstetrics, 21st edition. New York:

Mc Graw Hill Medical Publishing Division. 2001.

14. Nelson DA, Morris MW. Basic Examination of Blood.

Clinical Diagnosis and Management, 18th edition. Henry

JB: editors Philadelphia: W.B. Saunders Company. 1991.

15. Anwer S, Mustafa S. Rapid Identification of Neonatal

Sepsis. Journal of Pakistan Medical Association. 2000;

50(3).

16. Limjoco-Sarte L, Gonzales RM. Septicemia in Filipino

Infants and Children: Analysis of 724 Bacteriologicallly

Proven Cases in an Urban Hospital. Philippine Journal of

Pediatrics. 1981; 30(6): 190-198.

17. Rodwell RL, Tudehope DA. Early diagnosis of neonatal

sepsis using a hematologic scoring sytem. The Journal

of Pediatrics. 1988; 112(5): 761-767.

18. Akenzua GI, Hui YT, Milner R, Zipursky A. Neutrophil

and Band counts in the Diagnosis of Neonatal Infections.

Pediatrics. 1974; 54(1): 38-42.

19. Engle WD, Rosenfeld CR. Neutropenia in high risk

neonates. The Journal of Pediatrics. 1984; 105(6): 982-

986.

neonates. Since this scoring system is highly sensitive

and specific for neonatal sepsis, it could also serve as

the basis for a more rational approach to antibiotic use.

A significant decrease in the use of antibiotics may prevent

the emergence of resistant organisms, decrease the

chance of side effects and minimize cost.

RECOMMENDATIONS

It is recommended that more subjects will be

included in future studies wherein there will be a control

group composed of healthy, asymptomatic neonates and

a test group composed of neonates with probable sepsis

or proven sepsis. The group can also be divided into full

term or preterm neonates to determine differences in

their hematological characteristics. It also suggested that

one interpreter of the laboratory results be assigned to

decrease the observer variability.

REFERENCES

1. Manucha V, Rusia U, Sikka M, Faridi MMA, Madan N.

Utility of hematological parameters and C-reactive protein

in the detection of neonatal sepsis. Journal of Pediatrics

and Child Health. 2002; 38: 459-464.

2. Baley J, Goldfarb J, Neonatal Infections. Care of the high

risk neonate, 4th edition. MH. MH Klaus and AA Fanaroff:

editors. Philadelphia: WB Saunders Company, 1993.

3. David E., Tan CT, Que SP., Cruz NGS. Determining the

criteris for early discontinuation of antibiotic therapy in

suspected neonatal sepsis. Philippine Journal of

Microbial Infectious Diseases. 1980; 9 (2): 145-155.

4. Annual Reports of the Section of Neonatology of the

Department of Pediatrics UP-PGH Medical Center. 2000-2002.

5. Bellig L, Ohning B. Neonatal Sepsis. EMedicine Journal

Pediatrics/Neonatology. 2003; 4(1). 6. Thilo EH,

Rosenberg AA. Infections of the Newborn. Current


44

SERUM CONCENTRATION OF PYRAZINAMIDE SUSPENSION IN

CHILDREN WITH TUBERCULOSIS: A THERAPEUTIC DRUG

MONITORING

Daisy O. Sanchez, MD*, Cecilia C. Maramba, MD*

ABSTRACT

Rationale. Therapeutic drug monitoring (TDM) is a

process of adjusting drug dosages on the basis of serum

drug concentrations for the purpose of optimizing drug

therapy. This study introduces the use of TDM in the

management of mycobacterial infections. Pyrazinamide

(PZA) has been marketed as tablet in other countries.

It is only in the Philippines wherein pyrazinamide is

available both in tablet and suspension forms. No study

has been done on pyrazinamide suspension use for the

treatment of tuberculosis to this date.

Objectives. To examine the serum concentration of

pyrazinamide suspension in children with tuberculosis

Design. Descriptive study

Methods. Thirty pediatric patients who were taking

pyrazinamide suspension for at least 1 week as part of

chemotherapy for tuberculosis were included in this study.

Blood was taken prior to the dose then 2, 4, 8 hours after

administration of PZA suspensiongfor thefirst 4 patients.

Specimens were submitted to the Pharmacology

Department Laboratory of the University of the

Philippines – College of Medicine and were analyzed

using High Performance Liquid Chromatography

technique. The samples from the first 4 patients were

used to determine the time when the drug reaches its

maximum concentration (Tmax). For subsequent

patients, 2 determinations were taken at the time when

the drug reaches its maximum concentration and trough

level.

Results. At at a Tmax of 2 hours, the mean serum

concentration of PZA suspension is at 34.6+ 11.86 ug/

ml. The mean serum trough level is 4.55+ 4.63 ug/ml.

There were no significant differences in serum

concentration of PZA suspension among 3 brand names

of PZA (p-value: 0.506).

Keywords. Pyrazinamide, antituberculosis, therapeutic drug monitoring, pharmacokinetics,

tuberculosis


Conclusion. Mean serum concentration of PZA

suspension falls within the established therapeutic range

for pyrazinamide. But 2 subjects failed to reach the

therapeutic levels. No subject reached toxic levels

INTRODUCTION

In the past 4 years, tuberculosis ranks 6th in the

leading causes of morbidity in the Philippines. It is also

the 5th leading cause of mortality from 1989-1993.

Children under 15 years of age represent 1.3 million cases

per year and 450,000 deaths per year. Despite the

widespread use of BCG vaccine and the availability of

effective drugs, TB remains a major health problem. The

eradication of TB has proven to be an elusive goal for

clinicians and policy-makers. Failure of TB control is

not a new phenomenon in our country. Several factors,

including irrational antibiotic use, collapse of public health

infrastructures, the HIV epidemic, war, famine, increasing

inequality and poverty, and prohibitive cost of medicines,

have all contributed to the increasing incidence of TB all

over the world. In certain situations, drugs provide

suboptimal serum concentrations and these are associated

with worse treatment outcomes. Recurrence occurs in

2.4-5.5% of cases even when the patient receives directly

observed treatment. It is important to maintain high

standards of quality assurance, as low quality drugs often

penetrate emerging markets, resulting in low cure rates

for patients and increased resistance.

Definition of Terms

1. Therapeutic drug monitoring (TDM) – is the process

of using serum drug concentrations to optimize drug

therapy. TDM is useful when serum concentrations

show a better correlation with the therapeutic effects

or the incidence of adverse effects than does the

size alone. TDM requires the accurate timing of

doses and blood collection and the avoidance of assay

interferences.


45

2. Tmax – time when drug reaches maximum/peak

serum concentration

3. Trough – serum concentration of the drug at time 0

4. Cmax - peak serum concentration

Review of literature

Pyrazinamide is one of the most frequently

administered drugs for the treatment of TB. It was

synthesized in the 1940s by Hall and Spoerri and formerly

used only as salvage therapy. Convincing results of

experimental studies have elevated it to a central role in

tuberculosis chemotherapy as an essential addition to

isoniazid and rifampicin which make it possible to shorten

the treatment to 6 months. The major contribution of

pyrazinamide is to increase the sterilizing power of an

antituberculosis regimen, measured by prevention of

relapse after initially successful therapy. Pyrazinamide

is administered at 15-30 mg per kg with a maximum daily

dose of 2 grams. When administered twice weekly, the

dose of pyrazinamide is 50-70 mg/kg/dose with a

maximum dose of 4 grams. A randomized, four-period,

crossover study, a single oral dose of 30 mg/kg of

pyrazinamide tablet in a fasting state results in a mean

peak serum concentration of 53.4 ug/ml at 1.43 hours. 11

The mean serum concentration of pyrazinamide tablet

was slightly increased by antacid and modestly decreased

by food (p=0.0138). The optimum sampling time was 1

hour after the dose, which is the closest to Cmax.

Similarly, a prospective study of C. Lacroix regarding

pyrazinamide kinetics in 9 healthy subjects showed a rapid

absorption in the fasting state (tmax </= 1 hour).12 In

Peloquin’s two-way, randomized, crossover study of

isoniazid, rifampicin, and pyrazinamide in 1997, the

calculated steady-state range for pyrazinamide (dose of

20mg/kg) was 27.03 to 53.12 ug/ml.16

Current knowledge on PZA came from results

described mostly in healthy volunteers. However, the

pharmacokinetics of pyrazinamide in children with

tuberculosis differ from that found in healthy volunteers.

In the prospective, multiple-dose population

pharmacokinetic study of Min Zhu has shown these

differences.17

Pyrazinamide has been marketed as tablet (500

mg) in other countries. In the Philippines, it is available

in tablet and suspension form. The suspension form

(250mg/5 ml) is very unstable. It crystallizes when it is

allowed to stand in room temperature and especially when

it is refrigerated. Much of the studies published to this

date used the tablet form of the drug. Bioavailability

studies on PZA were based of the tablet preparation.

Locally, according to the Bureau of Food and Drug

Administrative Order 67 series of 1989, all drug

manufacturers, traders and distributors are required to

submit bioavailability tests on the products sought to be

registered. At present, there are 5 existing brands of

pyrazinamide in the market. The purpose of this study is

to determine the serum level of pyrazinamide suspension

in order to optimize drug therapy and verify that they

achieve the therapeutic level. The National Jewish Center

for Immunology and Respiratory Medicine proposed a

therapeutic range for PZA at 2-hour which is at 20-60

ug/ml. Generally speaking, drug concentration at the site

of drug action are difficult to determine and typically not

obtainable. Therapeutic drug monitoring assumes that

there is a better correlation between serum concentration

and drug effects than between the dose prescribed and

the drug effects.

Peloquin of the Infectious Disease

Pharmacokinetics Laboratory in Denver suggested an

approach to the use of antibiotic serum concentration.15

It is clear that some drug concentration is required to

achieve a therapeutic effect. The target ranges should

be designed with a margin of safety with respect to their

efficacy. Once a decision is made to use a given

antibiotic, a goal should be set for the desired serum

concentration. Monitoring antimycobacterial drug levels

allows clinician to identify those patients who are not

absorbing, metabolizing or eliminating their drugs normally.

OBJECTIVES

General objective

To examine the serum concentration of PZA suspension

in children with tuberculosis

Specific objectives:

1. To present the demographic characteristics of

subjects in terms of the following: age, sex, duration

of therapy, organ of affectation

2. To compute the Tmax in 4 patients in order to

determine the correct timing of peak level in

subsequent patients

3. To compare the peak and trough of PZA suspension

in children with tuberculosis with the established

therapeutic range and duration of therapy

4. To compare the peak and trough levels of 3 most

commonly used brands of PZA suspension with each

other

METHODOLOGY

Study design. Descriptive study


46

Study population

Thirty pediatric patients who were taking PZA

suspension for at least 1 week as part of chemotherapy

for tuberculosis were included in this study. The subjects

were recruited from the TB registry of the INTROP

section of the Department of Pediatrics and from admitted

patients at Ward 11.

Inclusion criteria:

1. Thirty pediatrics patients diagnosed to have

tuberculosis of any organ and are taking PZA

suspension as part of antituberculosis therapy for at

least 1 week

2. normal CBC, serum creatinine, AST, ALT, uric acid

3. informed consent from parent or guardian

Exclusion criteria:

1. poor compliance with the medications

2. abnormal CBC, serum creatinine, AST, ALT, uric

acid

3. failure to give consent.

4. liver or renal insufficiency

5. adverse reactions to anti-TB medications

DATA COLLECTION

Last intake of pyrazinamide suspension of the

thirty patients is 24 hours prior to the procedure. The

investigator observed the patient take the pyrazinamide

suspension and recorded the exact date and time. Three

to five ml of blood was drawn from the subjects, who

were at least on their 2nd week of pyrazinamide

suspension therapy, via direct venipuncture. An indwelling

IV catheter attached to a heplock was inserted in order

to minimize punctures. Blood was taken prior to the dose

then 2, 4, 8 hours after administration of pyrazinamide

suspension. The specimens were placed in glass test

tubes labeled with the patient’s name, date and time of

collection, and the drug to be assayed. It was then

allowed to clot and then stored in an icebox at –20

degrees centigrade and was submitted to the

Pharmacology Laboratory of the UP-College of

Medicine. Blood specimens were centrifuged for 5

minutes. The plasma was analyzed using High

Performance Liquid Chromatography technique. This

method can measure the amount of pyrazinamide in the

blood to as low as 0.1 ug/ml. Samples for the first four

patients were used to determine Tmax. For subsequent

patients, 2 determinations were taken at Tmax and trough.

Outcome measured.

Serum concentration of pyrazinamide suspension in

children with tuberculosis


Frequency of distribution included measures of

central tendency for age, duration of treatment, serum

concentrations at hour 0 and 2. Differences among

subjects and groups were determined by analysis of

variance (ANOVA) model. Paired samples were

compared. Sample size calculations were based on an

estimated mean difference of 20 and a standard deviation

of the difference of 15. The test of equality of means

was carried out at 0.017 level of significance (overall

level of significance for pair wise comparisons of

pyrazinamide brand names is 0.05). A sample size of 9

pairs per brand name gives a probability of 0.815 of

rejecting the null hypothesis of equal means if the

alternative holds.

RESULTS

The characteristics of subjects who participated

in the study are described in Table 1 and 2. Thirty

subjects (16 males; 14 females) were included. The mean

age is 9.46 +/-4.65 (range: 1-18 years). The median

duration of therapy is 9 days (range: 7-35 days). The

subjects received 20-25 mg/kg/day of pyrazinamide

suspension in keeping with the standard clinical practice

of the institution. Twenty-six subjects have concomittant

intake (intravenously and orally) of other drugs on the

day of blood sampling such as oxacillin, cefepime,

penicillin G, cefuroxime, amikacin, furosemide,

acetazolamide, dexamethasone, prednisone,

phenobarbital, propranolol, lanoxin, kalium durule, vit B

complex, dibencozide and multivitamins. All of these

drugs were assayed to check for interference in

pyrazinamide level. Only acetazolamide was found to

interfere with the assay of pyrazinamide. All patients

received pyrazinamide in combination with other

antituberculosis drugs including isoniazid, rifampicin,

ethambutol and streptomycin. Among the study

population, 40% has pulmonary tuberculosis. This was

followed by tuberculous meningitis and Potts disease at

23% and 13%, respectively.


47

Table 1. Mean age and duration of therapy of patient population

Variable Mean Median Standard Range

Deviation

Age (years) 9.4667 10.5 4.6589 1.00-18.00

Duration of 12.1 9.0 8.1213 7.00-35.00

therapy

(days)

Table 2. Patient Population Demographics

Variable N Percentage

Male 16 53.3%

Female 14 46.6%

Organ of affectation

Lungs 12 40%

CNS 7 23.3%

Bone 4 13.3%

Disseminated 3 10%

Heart 2 6.6%

Endobronchial 1 3.3%

Kidney 1 3.3%

Table 3 shows that Tmax was determined using

the first four subjects. Based on the computation, Tmax

of 2 hours was used for the subsequent subjects (mean

of 2.98+/-1.1).

Table 3. Computed Tmax in first 4 patients

Patient Hour 0 Hour 2 Hour 4 Hour 8 Tmax

#1 4.24 20.25 8.43 4.55 2.28

#2 0.26 7.14 10.55 8.26 1.98

#3 12.17 24.06 23.09 15.85 4.44

#4 9.23 28.62 20.37 13.32 3.22

Table 4. Suspention trough and Tmax serum concentration

of pyrazinamide

Patient no. Duration Serum concentration (ug/ml)

of therapy 0 hour 2 4 8

(Through) (Tmax)

3 16 days 9.23 28.62 20.37 13.32

13 7 4.76 25.98

14 9 0** 58.64

17 7 2.94 45.80

22 10 0** 44.48

23 7 0** 42.02

24 10 0** 41.94

25 8 0** 21.48

28 7 8.02 38.62

29 10 13.97 52.58

1 30 days 0.26* 7.14 10.55 8.26

2 14 4.24 20.25 8.43 4.55

4 9 12.17 24.06 23.09 15.85

8 11 0.88* 34.36

9 9 4.19 27.05

10 30 14.49 43.53

18 9 0.85* 45.79

19 7 2.64 47.42

21 8 7.12 37.43

20 8 0.93* 24.30

PZA-CIBA by Novartis

6 35 days 0** 40.03

7 7 0.52 32.20

11 7 0** 16.55*

12 30 4.9 18.38*

15 7 3.28 22.35

16 7 3.83 40.45

26 9 9.28 38.81

27 9 10.10 34.62

28 8 11.62 44.95

5 18 6.49 37.32

ZINAPLEX by Pediatrica

*failed to reach therapeutic level (20-60ug/ml)

**trough levels <1ug/ml

ZCURE by Natrapharm


48

Table 5. Mean serum level of pyrazinamide suspension in

population grouped into brand names

Zinaplex n Mean Standard

ug/ml Deviation

Hour 0 0 3.8920 4.9944

Hour 2 0 40.0160 11.7294

Duration of therapy 0 9.1 2.7669

Zcure

Hour 0 0 4.7770 5.0055

Hour 2 0 31.1330 12.87226


PZA-Ciba

Hour 0 10 5.0020 4.2789

Hour 2 10 32.6660 9.9970


Repeated Measures Analysis of Variance was

used to analyze the data. Hour (0 hour, 2 hour) was

considered as within-subject effect; group (Zinaplex,

Zcure, PZA-Ciba) as between–subject effect and

duration as a covariate. A significant difference between

0 hour and 2 hours was noted (p-value: 0.000). However

there were no significant differences in serum

concentration of pyrazinamide suspension among three

brand names of pyrazinamide (p-value: 0.506).

Within-subject effects

Effect/Source p-value

Hour 0.000*

Hour•duration 0.378

Hour•group 0.242

Between-subject effects

Duration 0.550

Group 0.506

Table 6.

DISCUSSION

Subjects were grouped according to brand names

of pyrazinamide suspension. Ten subjects were included

for each brand name. The serum concentration of

pyrazinamide suspension and duration of therapy is

reported in Table 4. In the zinaplex group, half of the

subjects had a trough level of 0 ug/ml. On two occasions,

PZA-Ciba also had the same serum trough level, while 4

out of 10 subjects belonging to the Zcure group reported

a serum trough concentration of <1 ug/ml. Generally

speaking, a low to absent serum drug level prior to the

next dose indicates that the drug did not sustain the desired

serum concentration necessary for it to exert bactericidal

activity most probably because of its short half-life.

Pharmacodynamic parameters of efficacy can

either be concentration-dependent or time-dependent. In

concentration-dependent killing agents, the higher the drug

concentration, the greater the extent of bactericidal

activity (Cmax:MIC ratio). On the other hand, time-

dependent agents kill bacteria only when the concentration

at the site is higher than the minimum inhibitory

concentration or MIC (time of the concentration above

MIC). Thus, the extent of killing is dependent on the

time of exposure. Drug concentration at the site of drug

action or tissue sample is difficult to determine and that

is the why serum drug concentration represent the next

best alternative.

Previous studies have shown that the mean

serum concentration of pyrazinamide tablet in healthy

volunteers is at 5-7 ug/ml at the 23rd hour following

administration of 1.5 gram dose of pyrazinamide tablet

once daily (C. Peloquin, 1998). In addition, Min Zhu et

al in 2002 determined the population parameter of

pyrazinamide tablet in children and adults with

tuberculosis. The absorption of pyrazinamide tablet in

children was 32% slower than in adults. The median

Cmax was 21.1 ug/ml, which was almost 50% lower than

the adult value of 41.1 ug/ml. The volume of distribution

was 71% lower in children and the half-life was 43%

shorter for children. According to this data, children

appeared to absorb pyrazinamide tablet more slowly but

eliminated it more quickly than adults. Another study

done in India showed that slow absorption was also found

in 10 patients with tuberculosis, aged 6-12 years old after

a single oral dose of pyrazinamide tablet. It is not clear if

these differences were due to chance, formulation, brand

name, race, concurrent TB infection, or a combination of

these factors. Whether or not the trough level 0-1 ug/ml

is clinically significant, a full-scale pharmacokinetics and

pharmacodynamics on pyrazinamide suspension on

Filipino children needs to be done.

Table 3 presents the computed Tmax from the

first 4 subjects. There is a perceptible wide variability of

time for drug to reach maximum concentration. Again,

this could be due to several circumstances as mentioned

earlier. Additional research is needed to explore how

the derived parameters can be used to optimize

antituberculous drug therapy.

As regards to the Cmax, 93% of subjects were

able to achieve a serum concentration level which was

within the expected therapeutic range (mean 34.6+/-11.86

*Significant at the 0.05 level


49

ug/ml). Two out of the 30 patient population reported a

serum concentration of <20 ug/ml, both belonging to the

PZA-Ciba group. Zinaplex group had the highest mean

serum concentration of 40 +/- 11.72 ug/ml.

In terms of duration of therapy, the present study

shows that there is no significant difference in serum

concentration of pyrazinamide suspension as presented

in Table 6.

The therapeutic range of pyrazinamide has been

reported to be at 20-60 ug/ml. In our study, at Tmax of 2

hours, the mean serum concentration of pyrazinamide

suspension is 34.6+/-11.86 ug/ml. Thus, pyrazinamide

suspension provides sufficient serum drug level at the

second hour to elicit the desired therapeutic response.

The result of the present study justifies that the suspension

form achieves the desired serum concentration at Tmax

but this study poses many questions such as, what would

be the role of race, formulation, brand name in the serum

level of pyrazinamide; what is a better measure or

parameter of efficacy, Cmax:MIC or time>MIC? In this

context, the results of the present study might constitute

a useful baseline or reference for future bioavailability

studies on pyrazinamide suspension.

CONCLUSION

Serum concentration of pyrazinamide suspension

in 30 pediatrics patients aged 1-18 years old, who are on

this formulation for 7-35 days were analyzed in this study.

Forty percent of the study population had pulmonary

tuberculosis. The Tmax of 2 hours was used based on

the computed value from the first four subjects. The

mean serum trough level of pyrazinamide suspension is

4.557+/-4.63 ug/ml. Seven out of 30 subjects accounted

for the lowest serum trough level of 0 ug/ml, 5 of whom

belong to the zinaplex group. The mean serum

concentration of pyrazinamide suspension at Tmax is

within the therapeutic level for pyrazinamide and is

notably being achieved also by the suspension form.

However, there were two patients who failed to reach

therapeutic levels and both of them belong to the PZA-

Ciba group.

Zinaplex has the highest mean serum

concentration at 2 hour followed by PZA-Ciba and Zcure.

However, it also has the lowest mean serum trough level

and has the most numbered of subjects (5) that recorded

the lowest value of 0 ug/ml, but these differences did not

reach statistical significance.

This study also demonstrates that duration of

therapy does not significantly affect serum drug

concentration. Neither the duration of therapy nor the

brand name of the formulation statistically significantly

affect the serum drug level of pyrazinamide suspension

of Tmax.

RECOMMENDATION

A full-blown bioavailability study is needed to

confirm the kinetics of pyrazinamide suspension

particularly on Filipino children. The role of race,

formulation, burden of TB disease on serum drug level is

yet to be determined.


50

REFERENCES

1. Philippine Health Statistics 2001, DOH. www.doh.gov.ph

2. The Philippine Pediatric Society. Tuberculosis in Infancy

and Childhood, 2003, p.3

3. Rajesh Gupta, Jim Y. Kim, et al. Responding to Market

Failures in Tuberculosis Control. Science. August

2001;(293):1049.

4. Weis SE, Slocum PC, Plais FX, et al. The Effect of Daily

Observed Therapy on the Rates of Drug Resistance and

Relapse in Tuberculosis, New England Journal of Medicine,

1994;(330):1179-84.

5. Theodore Brody et al, Emma D. Underdown. Human

Pharmacology. Second Edition. St. Louis, Missouri:

Mosby-Year Book, Inc.,1994. p.6.

6. Hall SA, Spoerri PE. Synthesis in the Pyrazine Series II.

Preparation and Properties of Amino Pyrazine, Journal of

American Chemical Society 1940;(62):664-5.

7. Clini V, Grasi C. The Action of New Antituberculous Drugs

on Intracellular Tubercle Bacilli. Antibiotic Chemotherapy,

1970;(16):20-6.

8. Mitchison DA. Basic Mechanism of Chemotherapy. Chest

1979;(76):771-81.

9. Lawrence J. Geiter. Contribution of Pyrazinamide to

Antituberculosis Chemotherapy. The Journal of Infectious

Diseases, 1991;(164):610.

10. Pyrazinamide Drugdex Drug Evaluations. Micromedex

Healthcare series. 2003. (116).

11. Charles A. Peloquin, et al. Pharmacokinetics of

Pyrazinamide under Fasting Conditions, with Food, and

with Antacids. Pharmacotherapy 1998;(18):1205-1211.

12. C. Lacroix, T. Phan Hoang, J. Nouveau, C. Guyonnaud, G.

Laine, O. Lafont. Pharmacokinetics of Pyrazinamide and

its Metabolites in Healthy Subjects. European Journal of

Clinical Pharmacology 1989,(36):395-400.

13. Q.L. Kintanar. Bureau Circular 1997. Bureau of Food and

Drugs, Department of Health. www.doh.gov.ph

14. Charles A. Peloquin. Therapeutic Drug Monitoring:

Principles and Application in Mycobacterial Infections.

Drug Therapy, July 1992:31-54.

15. Charles A. Peloquin. Tuberculosis Drug Serum Levels.

Clinical Infectious Disease 2001, (33):584-585.

16. Charles A. Peloquin, et al. Population Pharmacokinetic

Modeling of Isoniazid, Rifampin, and Pyrazinamide.

Antimicrobial Agents and Chemotherapy, December

1997;41(12):2670-2679.

17. Min Zhu et al. Population Pharmacokinetic Modeling of

Pyrazinamide in Children and Adults with Tuberculosis.

Pharmacotherapy 2002;22(6):686-695.


51

THE ANALYSIS OF CLINICAL AND SOCIAL PROFILE OF

CONGENITAL RUBELLA SYNDROME SEEN AMONG UP-PGH

PATIENTS FROM THE YEARS 1993 - 2002 (A 10 YEAR PREVALENCE

REVIEW)

Coralee Lianko Agnas , MD*

Objectives :

1. To describe the socio-demographic profile of patients

with Congenital Rubella Syndrome (CRS) s e e n

in UP-PGH for the last 10 years.

2. To compare the clinical profile of patients with

Congenital Rubella Syndrome (CRS) seen in UP-PGH

to that of foreign published data.

3. To describe the frequency distribution of occurrence

of clinical findings of patients with Congenital

Rubella Syndrome (CRS).

4. To describe maternal factors such as antenatal

maternal viral infection and MMR vaccination

history among siblings with Congenital Rubella

Syndrome (CRS).

Design: A descriptive study design.

Methodology: There were total of 58 cases of

Congenital Rubella Syndrome (CRS) classified and

retrieved in the Biostatistics and Epidemiology Section

of the UP-PGH, OPD Division. The 58 case numbers

of identified diagnosis in the charts were tracked down

and analyzed if they fit in to the inclusion criteria of

the study.

Results: In the wide spectrum of clinical manifestations

of Congenital Rubella Syndrome (CRS), the youngest

patient brought in for consult is within the1st month

with the mean age of 8 months, with slight male

preponderance.

Baseline anthropometrics showed 30% of

infants classified as severely wasted although 20% of

study population had normal weight . Majority (69%)

had no stunting. Congenital catarract ranked the most

common clinical presentation of patients with CRS,

accounting for 24 cases (49%) followed by patent

ductus arteriosus of 15 cases (31%). Most clinical

findings that co-exists were: ocular, cranial, growth

retardation, cardiac and sensorineural findngs. There is

a high occurrence of antenatal maternal viral infection

in this review – accounting to about 37 cases (71%)

of study population.

Conclusions: This research study documented the

continued existence of CRS and majority of the

patients were delivered primarily by an unvaccinated

women. The disease continued to be dynamically

prevalent despite the illness is a vaccine preventable

occurrence.

INTRODUCTION:

Congenital Rubella Syndrome is a serious multi-

systemic disease with a wide spectrum of clinical

expression and sequelae. This is comprised of

constellation of birth defects which may occur when

the mother acquires the infection during pregnancy ,

especially on her 1st trimester . In Congenital Rubella

Syndrome (CRS) virtually every organ system maybe

involved , singly , multiply , transiently or progressively

and permanently.

The risk of congenital defects of the disease

is greatest with the primary maternal infection during

the first trimester which may lead to abortion , stillbirth,,

or a child with anatomic defects. The risk is about

90% if the infection occurs before 11th week of

pregnancy, and this decreases by 10-20% at the end

of the 1st trimester, with an overall risk of 70% and

maternal infection after the 16th week of pregnancy

poses low risk of congenital defects although fetal

infection may still occur.

From the records of Philippine General Hospital

from the years 1993-2002, there are still 56 cases of

congenital rubella syndrome (CRS) despite the

introduction of MMR vaccination by our DOH since

1983. What are the factors that may have contributed

to the Congenital Rubella Syndrome profile that is

still prevalent in our community at present times?

In the study of Elias, Erik on Rubella (August

2002) states that after licensing the live attenuated

vaccine in the US in 1969, a dropped has occurred in

the number of cases of Rubella and Congenital Rubella

Syndrome (CRS). As shown in the statistics of 1969

(from the total of 57,686 cases of rubella and 62

cases of CRS ). From 1992-1998, the cases of rubellaKeywords : congenital , epidemiology , socio-demographic , immunization , vaccination .

*Department of PEdiatrics, UP-PGH


52

recorded annually decreased by the range of 128-

364 cases and CRS decreased by 2-9 cases per

year, although 15 cases of isolated outbreaks were

still reported. The median cases per outbreak was 21

and most recent cases occurred in New York (1997-

1998), Kansas(1998) and Nebraska (1999).

Likewise , CRS continuous to occur despite 25

years of immunization program in Canada and still

requires further measures to eliminate this preventable

disease. Between the years 1986-1995, a mean of 3

cases of congenital rubella syndrome (CRS) per year

were reported to the Notifiable Diseases Reporting

System in Canada. (Infectious Disease and Immunization

Committee; Canadian Pediatric Society).

In Kuala Lumpur, Malaysiathe incidence of CRS

from 1993 - 1998 varies from 19-93 per 100,000

deliveries.13

In Canada, the epidemiologic pattern of rubella

underscored the importance of the collection and

analysis of information on demographic, vaccination

history, source of infection in relation to transmission

and outbreaks.2

In a local study done, one of the variables

considered was the educational attainment of parents

or guardians on how they perceive the disease entity

itself and the benefits of vaccination.17

In a GENEVA conference , held November 28,

2001, the UNICEF (United Nations Children’s Fund)

hailed the massive immunization of individual between

15 months to 25 years old , to significantly reduce

the cause of birth defects in children which is now

estimated to be about 110, 000 cases of CRS per

year worldwide.

The intent of this paper is to have a wide

panoramic view of the demographic and psychosocial

profile of Congenital Rubella Syndrome among Filipino

children to guide us in early diagnosis and subsequently

pave way for the policy makers to formulate a timely

medical intervention and prevention programs to abort

further spread of virus and hinder specific disabilities

for progressive deterioration.

GENERAL OBJECTIVE

To describe the clinical and social profile of

patients with Congenital Rubella Syndrome (CRS)

seen in UP-PGH from the years 1993-2002.

SPECIFIC OBJECTIVES:

• To describe the socio-demographic profile

of patients with Congenital Rubella Syndrome (CRS)

seen in UP-PGH for the last 10 years .

• To compare the clinical profile of patients in terms

of type and number of clinical signs of Congenital

Rubella Syndrome (CRS) seen in UP-PGH versus

foreign published data.

• To describe the frequency distribution of

occurrence of clinical findings of patients with

CRS seen in UP-PGH.

• To describe maternal factors such as frequency of

antenatal maternal viral infection and MMR

vaccination history among siblings with Congenital

Rubella Syndrome.

METHODOLOGY

Study design : Descriptive study design

Sample size/Population:

Population considered are all charity pediatric

patients seen and/or admitted at Pedia ER, OPD,

Wards 9 and 11, PICU, and NICU of UP-Philippine

General Hospital from years 1993-2002. Excluded in

the study were those admitted at paywards and other

departments who were not referred nor co-managed

by pediatric residents.

Inclusion criteria:

1. patients aged 1 month to 18 years old.

2. patients consulted and / or admitted at UP-PGH:

PER, OPD, Wards 9 and 11 and special areas like

PICU and NICU.

3. patients admitted in other wards but seen or co-

managed by pediatric residents.

4. patients whose charts met the clinical case definition

and classification of Congenital Rubella Syndrome

(CRS) in APPENDIX E and with pertinent data

needed in the study.

Exclusion criteria:

1. patients seen at paywards. or other departments

not referred or co-managed by pediatric residents.

2. patients more than 18 years old at the time of

consult.

Actual Methodology:

There was total of 58 cases of Congenital

Rubella Syndrome (CRS) classified and retrieved in

the Biostatistics and Epidemiology Section of the

Record Division, 5th floor OPD, UP-PGH which were

tracked down and analyzed if they fit in to the

inclusion criteria.


53

However, only a total of 52 charts were

reviewed. The rest were missing due to the typhoon

that has embarked Metro Manila in the past years

destroying considerable amount of old documents in

the years 1993-1994 in the attic of the record section.


In this research study , the test of 2 proportion

was used and the frequency distribution for descriptive

data was likewise adapted .

RESULTS and ANALYSIS

Eight-year incidence of CRS cases and

sociodemographic profile

A total of 52 patient charts from 1995 to 2002

were reviewed. The frequency distribution of congenital

rubella syndrome cases from years 1993-2002 is

summarized as figure 1-1. A gradual increasing trend

was seen in 1998 up to the last two previous years.

YEAR

YEAR

20022001200019991998199719961995

Fre

quency

16

14

12

10

8

6

4

2

0

8

14

7

4

2

3

77

Figure 1. Frequency distribution of confirmed and probable

CRS cases from 1993-2002, UP-PGH Data

The socio-demographic characteristics are

summarized in Table 1. The mean age was 8 months.

The youngest patient on the time of consultation was 1

month old while the oldest was 60 months old. There

was a slight male preponderance 29 (56%) as opposed

to females. Mean weight on consult was 5 kg while the

mean height was 65 cm. Thirty percent (30%) of these

children are classified as severely wasted while

20 % had normal weights. Majority (69%) had no

stunting.

Much of our registered patients come from the

greater Manila and Southern Tagalog area (65% & 30%

respectively), There were 9 patients identified living in

Paranaque City, 6 patients in Las Pinas City, while

Mandaluyong, Taguig and Quezon City had 4 each, and

Pasay, Caloocan, Makati and Metro Manila had 1 patient

each. Majority of the parents of congenital rubllea

syndrome (CRS) finished high school (26%), as compared

to those who finished collegiate level (19%), and no

formal education (13%).

Antenatal maternal infection and vaccination

The number of women who had a history of

rubella (confirmed by history alone) is summarized in

Figure 2. There is a high occurrence (37 out of 52) of

antenatal maternal rubella in this review, while 12 mother’s

charts did not indicate the presence or absence of rubella

exposure. Two siblings underwent MMR vaccination and

this was seen in the years 2001 and 2002 respectively.

YEAR

20022001200019991998199719961995

Count

10

8

6

4

2

0

RUBELLA

not inidcated

yes

5

8

5

4

1

3

5

6

3

6

2

1

2

1

Figure-2. Antenatal history of maternal rubella in CRS cases

from 1995-2002 , UP-PGH Data

Table-1. Socio-demographic characteristics of patients with

Congenital Rubella Syndrome seen from 1995-2002 , UP-PGH.

UP-PGH Patients with CRS Percentage

Characteristics N= 52 %Age in months 8 + 10

(mean + SD)Sex

Males 29 56

Females 23 44Baseline Anthropometrics

Length (mean + SD) 65.3 + 16 cmWeight (mean + SD) 5.7 + 3 kg

Waterlow ClassificationWasting

Normal 15 28.8

Mild 11 21.2Moderate 10 19.2

Severe 16 30.8Stunting

Normal 36 69.2

Mild 5 9.6

Moderate 7 13.5

Severe 4 7.7

Geographic DistributionCentral Luzon 1 19

Southern Tagalog 16 30.7Western Visayas 1 1.9NCR* 34 65.3

Educational Background of Parents•

No formal education• 7 13.5Elementary• 6 11.5High school• 14 26.9

College• 10 19.2Vocational• 2 3.8

Not stated 13 25*National Capital Region


54

The common clinical findings of CRS is tabulated in

table-2. Only 5 clinical findings were mentioned in the 52

charts, namely cataract, PDA, hepatitis, jaundice,

pulmonary artery stenosis, extrauterine growth

retardation, glaucoma and hemolytic anemia. Congenital

cataract ranked as the most common syndrome finding

accounting for 24 (49%) of cases, followed by PDA in

15 cases (31%). Barring the differences survey design

and geography, we roughly compared each proportion

of findings with that of an 11- year US- based

epidemiologic data previously published by Schluter et.al.

Among all the mentioned CRS findings, PDA, hepatic

derangement and pulmonary artery stenosis was

statistically significantly higher in the US. This could be

explained by the relatively early detection of

abnormalities. (p-value <.05). Other socio-economic

variables, such as cost for diagnostic work-up , short

hospital stay and even parent preference may possibly

explain the low sign/symptom detection rate of the above

3 findings in our setting.

Table 2. Clinical Findings of CRSClinical UP-PGH Foreign p-value

Findings *N=122(%) Census

(ranked)*

Cataract 23(44) 55(45.1) .628

Patent Ductus 16(31) 62(50.8) .22^

Arteriosus (PDA)

Hepatomegaly/ 5(10) 43(35.2) .0009^

Hepatitis

Jaundice 5(10) 18(14.8) .3955

Pulmonary Artery 3(6) 22(18) .04^

Stenosis

Extrauterine Growth 2(4) 15(12.3) .94

Retardation

Glaucoma 1(2) 4(3.3)

Hemolytic Anemia 1(2) rare NA***

Clinical Profile of Congenital Rubella Syndrome (CRS) cases

*Only 5 clinical signs were identified in this study.

Several signs co-exist

**Data from the Schluter et.al., Changing Epidemiology of CRS in the US,1985-

1996

^ p-value significant at <.05

***Not applicable

Syndrome Profile of CRS

In UP-PGH, we identified the frequency of

combinations of organ systems affected. (See figure-3).

From the years 1995 and onwards, the presence of

cataract was a consistent syndrome finding. Cardiac

findings, PDA, PAS and ASD were not that common.

Jaundice and hepatosplenomegaly had been shown to be

consistent, although less common.

The combinations of findings were not accurately

determined in this review due to several reasons. Each

patient came in at different periods of the follow-up, the

presenting symptoms might have not incited a high index

of suspicion so as to subject the patient to intensive work-

up. So far, in this study , ocular plus cranial plus growth

retardation plus sensorinueral findings and cardiac

findings is still the most common combination.

Figure-3 Syndrome Profile of Congenital Rubella from 1995-

2002, UP-PGH Data

5

1

3

2

Cataract

sensorineural deafness

PDA

PAS

2002

10

1

6

4

11

1

Cataract


PDA

PAS

microcephalymeningoencephalitis

Hepatitis/ jaundice

2001

7

1

2

4

1

1

1

Cataract

Microphthalmia

PDA

Microcephaly

Full anterior fontanelle

Blue Berry muffin

syndrome

Thombocytopenic purpura

2000

3

2

1

1

1

1

1

11

Cataract

EUGR

Sensorineural deafness

PDA

PAS

ASD

Microcephaly

Mental retardation Hepatosplenomegaly

1999

1

1

1

Cataract

EUGR

Hepatitis/Jaundice

1998

21

2

Cataract EUGR

PDA

1997

4

1

3

2

1

3

2

1

2

Cataract

EUGR

PDA

PAS

VSD

Microcephaly

TTP

Blueberry Muffin Syndrome

Hepatitis/Jaundice

1996

44

2

2

2

2

Cataract alonePDA

Microcephaly

hepatitis/jaundice

hepatosplenomegaly

generalized

lymphadenopathy

1995

Fre-

quency

Findings

n=52

Year

5

1

3

2

Cataract


PDA

PAS

2002

10

1

6

4

11

1

Cataract


PDA

PAS

microcephalymeningoencephalitis

Hepatitis/ jaundice

2001

7

1

2

4

1

1

1

Cataract

Microphthalmia

PDA

Microcephaly

Full anterior fontanelle

Blue Berry muffin

syndrome

Thombocytopenic purpura

2000

3

2

1

1

1

1

1

11

Cataract

EUGR

Sensorineural deafness

PDA

PAS

ASD

Microcephaly

Mental retardation Hepatosplenomegaly

1999

1

1

1

Cataract

EUGR

Hepatitis/Jaundice

1998

21

2

Cataract EUGR

PDA

1997

4

1

3

2

1

3

2

1

2

Cataract

EUGR

PDA

PAS

VSD

Microcephaly

TTP

Blueberry Muffin Syndrome

Hepatitis/Jaundice

1996

44

2

2

2

2

Cataract alonePDA

Microcephaly

hepatitis/jaundice

hepatosplenomegaly

generalized

lymphadenopathy

1995

Fre-

quency

Findings

n=52

Year


55

DISCUSSION :

Since the introduction of MMR (measles,

mumps, rubella) vaccine in the Philippines since the

year 1983, there remains sporadic cases of CRS that

occurs in the country and eradication of the disease

seemed to be an elusive dream.

In this study there is not much appreciable

difference in the infection rates by sex distribution, a

difference of 4 cases (8%) of slight male

preponderance was noted. Only for the fact that

most of the disease was primarily noted during

“infancy period” where clinical features are clearly

seen if not without complications, except for 3 isolated

cases where patients presented beyond 3 years of

life and were noted to reside outside Greater Manila

Area (GMA), and sought consult at UP-PGH, for

definitive surgical correction of either congenital

catarract or cardiac anomaly.

The bulk of 34 cases (65%) out of 52

population were sporadically distributed along the

metropolis and 16 cases (32%) in region IV and

approximately (2%) in each of regions III and VI. A

large number of cases were seen in Metro Manila

where subjects are residing in the nearby vicinity of

the studied institution (UP-PGH) and could avail the

charity rates of medical consult and could take

advantage of the laboratories and medical manpower

the hospital could offer.

There is poor correlation of educational

attainment of parents to having a child infected with

congenital rubella syndrome (CRS). The study reflects

that the disease affects equally different people of

varying degree of literacy and levels of social strata,

which should alert the public health officials and mass

media to formulate infection control programs and

strategies to heightened public awareness of the spread

of infection since the disease targets the entire

population.

In the study of Schluter in the most frequent

clinical presentation of CRS is the sensorineural

deafness which is about 80-90% of the total population

followed by congenital catarract or glaucoma which

is about 35% and cardiac anomaly of roughly 30%.18

In our institution (UP-PGH) most of our

CRS cases sought consult due to ophthalmologic

problem; about 23 cases (44%) of the study group

population. Opacification of the lens from catarract

are more common (22 (42%) than glaucoma 1(2%))

followed by congenital heart defects of 19 cases

(36%) may which patent ductus arteriosus to be more

common than pulmonary stenosis accounting for 16

cases (84%) and 3 cases (16%) respectively.

According to written by Baja-Panlilio, et all.

The table of birth attendance , since 1990 documented

that most of our mothers; (40%) delivered at home

and attended by traditional birth attendant, and (30%)

by midwives, (1%) by nurse or others and only (27%)

by physician.19

And in most cases of non-institutionalized

delivery of high risks mothers , there is a missed

chance of the infant being evaluated by a trained

health care providers and corollary be worked up

and be seen by tertiary hospital subspecialties.

So, it follows that our congenital rubella

syndrome cases would present at OPD/PER with the

chief complaint of opacification of the eyes noted

during infancy or in blatant cardiac failure which is

probably due to inadequate anticipatory guidance

from our traditional birth attendants (TBA) and/or

midwives and which resulted to less preparatory

movement on the part of the parents.

In rich countries, where most mothers

delivered in a hospital, newborns have the benefit of

being seen by a pediatrician or neonatologist prior to

discharge and would present at ambulatory clinics

later life for either a child with neurodevelopmental

delay and/or for definitive management of hearing

impairment.

CONCLUSION:

This research study documented the continued

existence of CRS and majority of these born to

mothers, who had history of antenatal maternal viral

infection during pregnancy accounting for 37 cases

(71%) of the 52 study population . The disease

continued to be dynamically prevalent despite the

illness is a vaccine preventable occurrence .

It is therefore recommended for public health

officials to have high index of suspicion to the wide

spectrum of clinical manifestations of CRS and

subsequently send suspended infants for laboratory

work-ups, thereby improving the country’s surveillance

system and in turn improve the Filipinos’ quality of

future generation.

RECOMMENDATIONS:

Serologic testing of unvaccinated person for

rubella immunity before vaccination probably is not

necessary because this would only postpone the

opportunity for the vaccine to be administered.


56

Unless contraindicated, it is suggested that vaccine be

offered to: primary health care clinics, STD clinics,

travel clinics postpartum clinics, health care personnel,

and to all unvaccinated person who lack the evidence

of rubella immunity especially in child-bearing age

and foreign born individuals.

The state health department along with the

mass media should formulate programs and strategies

to heighten public awareness and consequently

educate its citizenry to bring patients to hospital for

diagnostics and early intervention of the impact of

associated disabilities and advice significant others

on ways and means to deter the further shedding of

virus in the community.

REFERENCES:

1. Behrman , Richard et.al., (2000) Nelson Textbook of

Pediatrics (16th edition) W.B. Saunders Company:pp 951-

953.

2. Reef , Susan , Coronado ,Victor: Congenital Rubella

Syndrome , Archive Page, www.deafandblind.com. Canada

Communicable Disease . Report: surveillance of CRS and

other rubella associated adverse pregnancy outcomes

, March 1,1996, Vol.22-05.

3. Canadian Pediatric Society, Prevention of Congenital

Rubella Syndrome; Ontario, Canada. Pediatrics and

Child Health ; 1999 pp 155-157.

4. Lambert , Scott.,Tychslu, Lawrence: Advances in Surgical

Management: Congenital/juvenile Cataract, November

2002.

5. Sharp, Merck and Dohme et all. General Information of

the Disease and the Vaccine, Asia: September 2002

6. Mitz, Sanchez, Scandas: Does Rubella Vaccination

prevent CRS; Vaccination Home Page, July 26, 2002.

7. Elias Ezike et al. August 21 , 2002. Rubella. Department

of Pediatrics, Division of Pediatric Infectious Disease;

Children’s Hospital: Michigan.

8. Mehlita M, Nehlish and Thomas Roslyn. Antenatal

Screening for Rubella – infection or immunity? NICU,

Northwick Park Hospital, Harrow, HAI 3UJ, British

Medical Journal, 2002.

9. Dominique, Marie MD. Screening and vaccinating

adolescents and adults to prevent congenital rubella

syndrome. Canadian Task Force on Preventive Health

Care. January 1994.

10. The Forsight Foundation . Referrence Site for Congenital

Rubella Syndrome , 2002.

11. Save the Children Foundation . A slender Thread: The

Vulnerable Newborn. USA, May 8, 2003.

12. UNICEF. Campaign to prevent Birth Defects in Central

Asia. UNICEF, Media, New York 1996 - 2003.

13. Kaw Bing, Chua and Sai Kit, Lam. Congenital Rubella –

Possible Threat to the New Millennium. Department of

Microbiology, University of Malaya , Kuala Lumpur, April

2003 .

11. Center for Disease Control. Rubella and Congenital

Rubella Syndrome – United States, 1994—1997. USA,

1997.

12. Center for Disease Control. Control and Prevention of

Rubella: Evaluation and Management of Suspected

Outbreaks, Rubella in pregnant women , Surveillance for

CRS. July 11, 2003.

13. Whitemeyer, Sharon MD. Rubella (German Measles).

University of New Mexico .Health Sciences Center , May

2003.

14. Ala , Romeo, MD; Mantos , Donna Belle, MD; Rodriquez,

Jose, MD . Factor Affecting Maternal Compliance to

Expanded Program of Immunization. Department of

Medicine, Cebu City, 1986.


57

Documents

PIDSP Journal, 2005 Vol. 9 No. 2 PIDSP JOURNAL