Siyuan Jiang

Importance: The Chinese Neonatal Network was established in 2018 and maintains a standardized national clinical database of very preterm or very low-birth-weight infants in tertiary neonatal intensive care units (NICUs) throughout China. National-level data on outcomes and care practices of very preterm infants (VPIs) in China are lacking. Objective: To assess the care practices in NICUs and outcomes among VPIs in China. Design, Setting, and Participants: A cohort study was conducted comprising 57 tertiary hospitals from 25 provinces throughout China. All infants with gestational age (GA) less than 32 weeks who were admitted to the 57 NICUs between January 1 and December 31, 2019, were included. Main Outcomes and Measures: Care practices, morbidities, and survival were the primary outcomes of the study. Major morbidities included bronchopulmonary dysplasia, severe intraventricular hemorrhage (grade ≥3) and/or periventricular leukomalacia, necrotizing enterocolitis (stage ≥2), sepsis, and severe retinopathy of prematurity (stage ≥3). Results: A total of 9552 VPIs were included, with mean (SD) GA of 29.5 (1.7) weeks and mean (SD) birth weight of 1321 (321) g; 5404 infants (56.6%) were male. Antenatal corticosteroids were used in 75.6% (6505 of 8601) of VPIs, and 54.8% (5211 of 9503)were born through cesarean delivery. In the delivery room, 12.1% of VPIs received continuous positive airway pressure and 26.7% (2378 or 8923) were intubated. Surfactant was prescribed for 52.7% of the infants, and postnatal dexamethasone was prescribed to 9.5% (636 of 6675) of the infants. A total of 85.5% (8171) of the infants received complete care, and 14.5% (1381) were discharged against medical advice. The incidences of the major morbidities were bronchopulmonary dysplasia, 29.2% (2379 of 8148); severe intraventricular hemorrhage and/or periventricular leukomalacia, 10.4% (745 of 7189); necrotizing enterocolitis, 4.9% (403 of 8171 ); sepsis, 9.4% (764 of 8171); and severe retinopathy of prematurity, 4.3% (296 of 6851) among infants who received complete care. Among VPIs with complete care, 95.4% (7792 of 8171) survived: 65.6% (155 of 236) at 25 weeks' or less GA, 89.0% (880 of 988) at 26 to 27 weeks' GA, 94.9% (2635 of 2755)at 28 to 29 weeks' GA, and 98.3% (4122 of 4192) at 30 to 31 weeks' GA. Only 57.2% (4677 of 8171) of infants survived without major morbidity: 10.5% (25 of 236) at 25 weeks' or less GA, 26.8% (48 of 179) at 26 to 27 weeks' GA, 51.1% (1409 of 2755) at 28 to 29 weeks' GA, and 69.3% (2904 of 4192) at 30 to 31 weeks' GA. Among all infants admitted, the survival rate was 87.6% (8370 of 9552)and survival without major morbidities was 51.8% (4947 of 9552). Conclusions and Relevance: The findings of this study suggest that survival and survival without major morbidity of VPIs in Chinese NICUs have improved but remain lower than in high-income countries. Comprehensive and targeted quality improvement efforts are needed to provide complete care for all VPIs, optimize obstetrical and neonatal care practices, and improve outcomes.

Objectives: To describe the rates and variability of mortality and morbidity of preterm infants born in China. Methods: This prospective cohort study included infants born at <34 weeks’ gestation and admitted to 25 NICUs within 7 days of birth between May 1st, 2015 and April 30th, 2016. Infants were followed until death or NICU discharge. The primary outcome was a composite of mortality or any major morbidity (sepsis, necrotizing enterocolitis, intraventricular /periventricular leukomalacia, retinopathy of prematurity, and bronchopulmonary dysplasia) in infants who received complete care following medical advice. Secondary outcomes included rate of discharge against medical advice, mortality and individual morbidities. Results: Of the 8065 infants, 6852 (85%) received complete care and 1213 (15%) were discharged against medical advice. Among infants who received complete care, the rate of the composite outcome was 27% (1827/6852), mortality 4% (248/6852), sepsis 14% (990/6852), necrotizing enterocolitis 3% (191/6550), intraventricular hemorrhage/ periventricular leukomalacia 7% (422/6307), retinopathy of prematurity 2% (67/3349), and bronchopulmonary dysplasia 9% (616/6852). There were significant variations between NICUs for all outcomes. Conclusions: Discharged against medical advice, mortality, and morbidity rates for preterm infants <34 weeks’ gestation are high in China with significant variations between NICUs.

OBJECTIVE: To describe the incidence, case-fatality rate and pathogen distribution of late-onset sepsis (LOS) among preterm infants in China. To investigate risk factors and short-term outcomes associated with LOS caused by Gram-positive bacteria, Gram-negative bacteria and fungi. METHODS: This cohort study included all infants born at <34 weeks' gestation and admitted to 25 tertiary hospitals in 19 provinces in China from May, 2015 to April, 2018. Infants were excluded who died or were discharged within 3 days of being born. RESULTS: A total of 1199 episodes of culture-positive LOS were identified in 1133 infants, with an incidence of 4.4% (1133/25,725). Overall, 15.4% (175/1133) of infants with LOS died and 10.0% (113/1133) of infants died within 7 days of LOS onset. Among 1214 isolated pathogens, Gram-negative bacteria were the most common (51.8%, 629/1214) and fungi accounted for 17.1% (207/1214). Use of central lines, longer duration of antibiotics and previous carbapenem exposure were related to increased risk of fungal LOS compared with Gram-positive bacteria. Gram-negative bacteria LOS was independently associated with increased risk of death, periventricular leukomalacia, bronchopulmonary dysplasia, and necrotizing enterocolitis. Fungal LOS was independently associated with increased risk of periventricular leukomalacia, bronchopulmonary dysplasia and necrotizing enterocolitis. CONCLUSIONS: Late-onset sepsis was a significant cause of morbidity and mortality in Chinese neonatal intensive care units, with a distinct pathogen distribution from industrial countries. Clinical guidelines on the prevention and treatment of LOS should be developed and tailored to these LOS characteristics in Chinese neonatal intensive care units.

BACKGROUND: The epidemiology of early-onset sepsis (EOS) in China is poorly understood because of the paucity of high-quality data. We aimed to examine the epidemiology, pathogen distribution and neonatal outcomes of EOS among a large cohort of preterm infants in China. METHODS: All infants born at <34 weeks of gestation and admitted to 25 tertiary neonatal intensive care units in China from April 2015 to May 2018 were enrolled. EOS was defined as a culture-confirmed infection that occurred within 72 hours after birth. RESULTS: Among 27,532 enrolled infants, 321 (11.7 cases per 1000 admissions) infants developed EOS, and 61 (19.0%) infants died within seven days after EOS onset. The incidence of EOS among inborn infants in 18 perinatal centers was 9.7 cases per 1000 live births <34 weeks' gestation (186/19,084). The case fatality rate was 22.6% (42/186). Gram-negative bacteria were responsible for 61.7% of EOS and 82.0% of EOS-related deaths. Escherichia coli (20.3%) was the leading pathogen, followed by Coagulase-negative staphylococcus (16.5%), Achromobacter xylosoxidans (9.0%) and Klebsiella pneumoniae (8.1%). Group B streptococci infections were relatively rare (2.5%). EOS was an independent risk factor for all-cause mortality and retinopathy of prematurity. CONCLUSIONS: There is a high burden of EOS among preterm infants in China with a distinctive pathogen distribution. Longitudinal epidemiologic monitoring, further investigation of causative pathogens and development of targeted strategies for prevention and treatment of EOS are needed.