Prevention of Early-Onset Group B Streptococcal Disease

Current U.S. guidelines for reducing the incidence of early-onset group B streptococcal disease in neonates recommend either screening pregnant women for infection or using the presence of clinical risk factors to identify candidates for intrapartum antibiotic prophylaxis. This multicenter, retrospective study compared the rates of early-onset group B streptococcal disease among infants born to mothers who had a documented culture for group B streptococcus during pregnancy (screened group) and those born to women with no screening documented (presumed "risk-based" group). The risk of early-onset disease in the screened group was half that in the risk-based group. Potential misclassification in the risk-based group of women whose providers had no defined strategy did not explain the observed results, since the lower risk persisted after the exclusion of women who had clinical risk factors warranting prophylaxis but did not receive it.

Universal prenatal screening for group B streptococcal colonization appears to be more effective in reducing the incidence of early-onset group B streptococcal disease than the use of clinical risk factors to identify candidates for intrapartum antibiotic prophylaxis. These findings suggest the need to reconsider current recommendations endorsing both approaches.

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Pathogens Causing Early-Onset Sepsis in Very-Low-Birth-Weight Infants

In this study, to assess whether the increasing use of intrapartum antibiotics to reduce neonatal group B streptococcal infection has been associated with changes in the rate and causes of early-onset sepsis in very-low-birth-weight infants, the authors compared the incidence of early-onset sepsis (that occurring within 72 hours of birth) among infants weighing 401 to 1500 g who were born between 1998 and 2000 with an earlier cohort of very-low-birth-weight infants born between 1991 and 1993. As compared with the 1991–1993 cohort, there was a marked reduction in group B streptococcal sepsis in the 1998–2000 cohort but an increase in Escherichia coli sepsis, such that the overall rate of early-onset sepsis was not significantly changed. Infants with early-onset sepsis were more likely to die than uninfected infants.

The change in causes of early-onset sepsis over time, from predominantly gram-positive to gram-negative organisms, requires confirmation, but this finding arouses concern about a possible adverse effect of broader use of antibiotics during labor and delivery.

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Kidney Transplantation from Donors without a Heartbeat

The shortage of renal allografts has led to interest in sources of organs other than living donors and cadaveric donors with a heartbeat. Accumulating data suggest that the short-term survival of cadaveric kidneys from donors without a heartbeat is similar to that of kidneys from donors with a heartbeat. This report describes a single-center study of 122 patients who received kidney transplants from donors without a heartbeat and 122 matched patients who received transplants from donors with a heartbeat. Recipients were followed for up to 15 years. Although there was a significantly higher incidence of initial delay in graft function among those who received kidneys from donors without a heartbeat, long-term graft survival was similar in the two groups.

Renal allografts from cadaveric donors without a heartbeat may be transplanted safely and with an acceptable outcome.

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Dermoid Inclusion Cysts and Early Spinal Cord Tethering after in Utero Surgery for Myelomeningocele

In utero surgery for myelomeningocele has been proposed to reduce neurologic dysfunction that may result from exposure of the spinal cord to amniotic fluid; approximately 220 such surgeries have been performed to date. The authors report on three girls under one year of age who had loss of motor function in the legs or loss of bladder function after in utero repair of myelomeningocele at 22 to 24 weeks of gestation. All three had dermoid cysts with associated spinal cord tethering, which required surgery.

Although in utero surgery for myelomeningocele holds promise for improving the neurologic outcome, these cases of early spinal cord tethering and dermoid-cyst formation sound a note of caution. There is a need for long-term assessment of children who undergo closure of myelomeningocele in utero, as compared with those in whom closure is performed after birth.

Related Perspective

Medical Progress: Polymyalgia Rheumatica and Giant-Cell Arteritis

Polymyalgia rheumatica is an inflammatory disorder manifested principally by stiffness of the neck, shoulder girdle, and pelvic girdle; giant-cell (or temporal) arteritis affects the cranial branches of arteries arising from the aortic arch. The two conditions are believed to be linked and may occur together. Giant-cell arteritis is a serious disorder that can cause blindness as a result of ischemia of the optic nerve or retina. Both disorders respond to corticosteroid therapy. This comprehensive article reviews the clinical manifestations, pathophysiology, and treatment of these disorders.

Sounding Board: Solid-Organ Transplantation in HIV-Infected Patients

Many centers do not consider asymptomatic HIV-positive patients to be candidates for solid-organ transplantation, although there are no data to indicate that the outcome of transplantation is worse among these patients than among other transplant recipients. This Sounding Board reviews the ethical arguments for considering tranplantatation in patients with HIV infection as similar to transplantation in patients with other chronic illnesses.

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