Preventing Infection in Newborns

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Interviewer: "Hi, I’d like to introduce Dr. Richard Polin who will be speaking to us from Salzburg on how to prevent infection in the newborn - Dr. Polin."

Dr. Richard Polin: "Yes, I’m a Professor of Pediatrics at the College of Physicians of Columbia University and Director of Neonatology at Columbia Presbyterian Medical Center and at Babies and Children’s Hospital in New York.

The question that I’ve been asked is how to prevent infections in the newborn. The most effective strategy is one, which has already been initiated by ACOG, AP, and CDC and that is the intrapartum use of antibiotics either for colonized women during labor and delivery or for women who have risk factors for infection. Unfortunately, that strategy is not completely effective in about 20%-25% of babies in whom the mothers receive intrapartum therapy still are born with early onset streptococcal sepsis. Therefore, recent attention has been directed towards other strategies or interventions, which might further decrease the risk of infection or lower the immortality-morbidity of infection. One such strategy which is yet untested but for which there’s a great theoretical and scientific argument, is the use of post-natal penicillin prophylaxis for asymptomatic infants born to either women whose colonization status is unknown or to women who receive inadequate treatment such as only an hour or two before delivery. A study completed in 1980, published by Segal MacCracken in the New England Journal of Medicine, suggested that 50,000 units of aqueous penicillin IN was an effective strategy to prevent early onset streptococcal sepsis. The estimates are that the use of intrapartum therapy plus selective use of post-natal penicillin prophylaxis might be effective in up to 90% of cases; however, a prospective trial has not been performed as yet.

The other strategies, which have been suggested as a way to prevent infection, include the use of intravenous immunoglobulin. IVIG contains antibodies that babies who are born prematurely may lack because there has not been enough time for transfer of antibodies from the maternal to the baby’s circulation. There have been approximately eighteen studies, which have looked at the prophylactic use of intravenous immunoglobulin to prevent nosocomial sepsis in newborn babies. If one performs a meta-analysis, it looks as if IVIG is an effective strategy but the two best studies to date - one performed by the NICHD on 2,400 babies and one performed by Carol Baker in Houston with about 600 babies, have yielded conflicting results. The NICHD study did not demonstrate an effectiveness of IVIG to prevent nosocomial sepsis where as the study by Carol Baker did. The studies were very different; they used different kinds of intravenous immunoglobulin at different doses and for different numbers of doses.

The feeling at this time is that IVIG might be an effective strategy if the preparation you’re using to give to a high-risk premature infant contains the right pattern of antibodies. Unfortunately, when you pull a vial off the shelf there’s no assurance it contains the antibodies against the kinds of pathogens which infect newborn babies which include streptococcus epidermitis, Candida, gram negatives, and that’s the reason probably for some of the discrepancy in the studies. The last possible intervention for decreasing nosocomial sepsis is to identify high-risk care practices, which are associated with an increased risk of nosocomial infection. The practices which have been identified thus far include the use of any indwelling catheter be it umbilical arterial or umbilical venous catheter, peripheral intravenous catheters, the use of post-natal steroids - not antenatal steroids, the use of H2 blockers, and the degree of illness obviously correlates with the U.S. spen-nosocomial infection. Therefore, as neonatologists we have to look at those care practices or risk factors and try to avoid them when we take care of sick newborn infants or at least use those interventions such as umbilical catheters for the shortest period of time."

Interviewer: "Thank you, Dr. Polin."