In neonates and infants who are receiving PN, septicemia may be a gut-related phenomenon.

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Background and aims: Patients receiving parenteral nutrition are at risk of septicaemia. Intestinal dysmotility and impaired gut immunity due to parenteral nutrition promote bacterial overgrowth. Gut overgrowth with aerobic Gram-negative bacilli (AGNB) impairs systemic immunity. The aim of this study was to determine the potential role of gut overgrowth with AGNB in the pathogenesis of septicaemia related to parenteral nutrition. Methods: A prospective 5 y study of surgical infants less than 6 months of age was undertaken. Surveillance samples of the oropharynx and gut were obtained at the start of parenteral nutrition and thereafter twice weekly, to detect AGNB carriage. Blood cultures were taken on clinical indication only. Results: Two-hundred and eight infants received parenteral nutrition for 6271 days (median 13 days, range 1 -512 days). The incidence of AGNB carriage was 42%, whilst the septicaemia rate was 15%. Eighty-four percent of septicaemic infants carried AGNB, whilst 16% never carried AGNB (P < 0.005). Carriage developed significantly earlier than septicaemia. Conclusions: The incidence of septicaemia was significantly greater in the subset of abnormal carriers. Although gut overgrowth with abnormal flora reflects illness severity, the fact that it preceded septicaemia implicates AGNB overgrowth, per se, as a contributory factor in the development of septicaemia related to parenteral nutrition. Prevention is unlikely to be successful if it ignores the abnormal flora.

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Primary peritoneal drainage (PPD) was initially introduced as a method for the pre-operative resuscitation of critically ill infants with complicated necrotising enterocolitis (NEC). Some have recommended it as definitive strategy for a select group of extremely low birth weight babies. The role of laparotomy in neonates who do not respond to initial PPD has also been challenged. With this background, we analysed our experience with the use of PPD in babies with NEC over an 18-year period. We retrospectively reviewed all patients with NEC who had PPD as their initial surgical management over an 18-year period. A total of 122 babies with NEC were treated surgically, of whom 42 had PPD as the initial procedure. There were 28 survivors (67%) in the PPD group, of whom 7 recovered without laparotomy. Twenty-nine infants (69%) had a good clinical response to PPD with 80% (23/29) survival, compared to a 27% survival (3/11) in those who did not respond to drainage. Six patients underwent rescue laparotomy after a poor response to PPD and three of these survived. Six of the 28 pts who underwent laparotomy had isolated intestinal perforation and their clinical characteristics were no different from those with typical NEC. PPD is a useful option in the management of complicated NEC. It is difficult to recognise with certainty those infants who will not require a subsequent laparotomy and therefore we do not support the concept of PPD solely as a definitive strategy. The response to PPD is a good prognostic indicator for ultimate survival. Despite a low salvage rate of 27% in non-responders compared to 80% in responders, there is a role for early laparotomy for those infants who do not respond to PPD.

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