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Thomas R, Ondongo-Ezhet C, Motsoaledi N, Sharland M, Clements M, Velaphi S. Incidence, pathogens and antimicrobial resistance of blood and cerebrospinal fluid isolates from a tertiary neonatal unit in South Africa: A 10 year retrospective review. PLoS One 2024; 19:e0297371. [PMID: 38241304 PMCID: PMC10798535 DOI: 10.1371/journal.pone.0297371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/29/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To determine trends in incidence, etiology and antimicrobial susceptibility of blood and cerebrospinal fluid (CSF) culture confirmed infections in hospitalized infants in a large tertiary neonatal unit in South Africa. METHODS Single-center, retrospective review of laboratory records of bacteria and fungi, and their susceptibility profiles, isolated from blood and CSF of infants hospitalized in the neonatal unit at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, from 1st January 2010 to 31st December 2019. Laboratory data on isolates and their antimicrobial susceptibilities were collected. Coagulase-negative Staphylococcus, Corynebacteria and Bacillus spp. were excluded. Patient-level clinical and laboratory data were not available. RESULTS There were 8,319 significant isolates, giving an infection rate of 14.3/1000 patient-days. Infection rates increased from 12.0 to 15.7/1000 patient-days (estimated average yearly change 0.6[95%CI, 0.5-0.7];p = <0.001). Gram-negative infection rates increased from 4.3 to 10.8/1000 patient-days (estimated average yearly change 0.7[95%CI,0.6-0.8];p = <0.001). The 2 most commonly isolated Gram-negative organisms were Acinetobacter baumannii (44%) and Klebsiella pneumoniae (39%). Carbapenem resistance was seen in 31% of all Gram-negatives and increased over time (estimated average yearly change 4.8%[95%CI,4.2%-5.3%];p<0.001). Gram-positive infection rates decreased (estimated average yearly change -0.1[95%CI,-0.2- -0.05];p = <0.001). Staphylococcus aureus was the most common Gram-positive isolated. Rates of methicillin-resistant Staphylococcus aureus decreased from 91% to 55%(estimated average yearly change -2.8%[95%CI,-3.5%-2%],p< 0.001). Rates of fungal isolates decreased (estimated average yearly change -0.06[95%CI,-0.1 --0.02]);p = 0.007). Candida parapsilosis (52%) and Candida albicans (35%) were the most common fungi isolated. CONCLUSIONS There has been a marked overall increase in rates of blood and/or CSF infections, with an absolute increase in Gram-negative infections observed, replacing Gram-positive and fungal pathogens. Extended spectrum beta-lactamase Gram-negative isolates are being replaced by carbapenem resistance, with around one third of all significant Gram-negative isolates now carbapenem resistant. Research into hospital based novel treatment and prevention interventions for neonatal sepsis should be urgently prioritized.
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Affiliation(s)
- Reenu Thomas
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Claude Ondongo-Ezhet
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Nini Motsoaledi
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mike Sharland
- St. Georges, University of London, London, United Kingdom
| | | | - Sithembiso Velaphi
- Faculty of Health Sciences, Department of Paediatrics, Chris Hani Baragwanath Academic Hospital and School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Kumar R, Setiady I, Bultmann CR, Kaufman DA, Swanson JR, Sullivan BA. Implementation of a 24-hour empiric antibiotic duration for negative early-onset sepsis evaluations to reduce early antibiotic exposure in premature infants. Infect Control Hosp Epidemiol 2023; 44:1308-1313. [PMID: 36278513 DOI: 10.1017/ice.2022.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Antibiotic exposure increases the risk of morbidity and mortality in premature infants. Many centers use at least 48 hours of antibiotics in the evaluation of early-onset sepsis (EOS, <72 hours after birth), yet most important pathogens grow within 24 hours. We investigated the safety and efficacy of reducing empiric antibiotic duration to 24 hours. DESIGN Quality improvement study. SETTING A tertiary-care neonatal intensive care unit. PATIENTS Inborn infants <35 weeks gestational age at birth (ie, preterm) admitted January 2019 through December 2020. INTERVENTION In December 2019, we changed the recommended duration of empiric antibiotics for negative EOS evaluations from 48 hours to 24 hours. RESULTS Patient characteristics before and after the intervention were similar. After the intervention, 71 preterm infants (57%) with negative EOS evaluations received ≤24 hours of antibiotics, an increase from 15 (10%) before the intervention. These 71 infants comprised 77% of infants with negative EOS blood cultures after excluding those treated as clinical sepsis (≥5 days of antibiotics). For all negative EOS blood cultures, the mean treatment duration decreased by 0.5 days from 3.9 days to 3.4 days. This finding equated to 2.4 fewer antibiotic days per 100 patient days for negative EOS blood cultures but similar antibiotic days per 30 patient days (7.2 days vs 7.5 days). This measure did not change over time. Subsequent sepsis evaluations <7 days after a negative EOS blood culture did not increase. Excluding contaminants, the median time to positivity was 13.2 hours (range, 8-23) in 8 positive blood cultures. CONCLUSION Implementation of a 24-hour antibiotic course for negative EOS evaluations safely reduced antibiotic exposure in 77% of infants <35 weeks gestational age at birth in whom EOS was ruled out. All clinically significant pathogens grew within 24 hours.
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Affiliation(s)
- Rupin Kumar
- Division of Neonatology, Department of Pediatrics, University of Kentucky School of Medicine, Lexington, Kentucky
| | - Initha Setiady
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Charlene R Bultmann
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - David A Kaufman
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Jonathan R Swanson
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
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Stocker M, Klingenberg C, Navér L, Nordberg V, Berardi A, El Helou S, Fusch G, Bliss JM, Lehnick D, Dimopoulou V, Guerina N, Seliga-Siwecka J, Maton P, Lagae D, Mari J, Janota J, Agyeman PKA, Pfister R, Latorre G, Maffei G, Laforgia N, Mózes E, Størdal K, Strunk T, Giannoni E. Less is more: Antibiotics at the beginning of life. Nat Commun 2023; 14:2423. [PMID: 37105958 PMCID: PMC10134707 DOI: 10.1038/s41467-023-38156-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
Antibiotic exposure at the beginning of life can lead to increased antimicrobial resistance and perturbations of the developing microbiome. Early-life microbiome disruption increases the risks of developing chronic diseases later in life. Fear of missing evolving neonatal sepsis is the key driver for antibiotic overtreatment early in life. Bias (a systemic deviation towards overtreatment) and noise (a random scatter) affect the decision-making process. In this perspective, we advocate for a factual approach quantifying the burden of treatment in relation to the burden of disease balancing antimicrobial stewardship and effective sepsis management.
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Affiliation(s)
- Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Dept. of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Lars Navér
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Viveka Nordberg
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Mother and Child Department, Policlinico University Hospital, Modena, Italy
| | - Salhab El Helou
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Gerhard Fusch
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Joseph M Bliss
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Richmond, USA
| | - Dirk Lehnick
- Biostatistics and Methodology, CTU-CS, Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Varvara Dimopoulou
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicholas Guerina
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Richmond, USA
| | - Joanna Seliga-Siwecka
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warszawa, Poland
| | - Pierre Maton
- Service néonatal, Clinique CHC-Montlegia, groupe santé CHC, Liège, Belgium
| | - Donatienne Lagae
- Neonatology and Neonatal Intensive Care Unit, CHIREC-Delta Hospital, Brussels, Belgium
| | - Judit Mari
- Department of Paediatrics, University of Szeged, Szeged, Hungary
| | - Jan Janota
- Neonatal Unit, Department of Obstetrics and Gynecology, Motol University Hospital Prague, Prague, Czech Republic
- Department of Neonatology, Thomayer University Hospital Prague, Prague, Czech Republic
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Riccardo Pfister
- Neonatology and Paediatric Intensive Care Unit, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Giuseppe Latorre
- Neonatology and Neonatal Intensive Care Unit, Ecclesiastical General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Gianfranco Maffei
- Neonatology and Neonatal Intensive Care Unit, Policlinico Riuniti Foggia, Foggia, Italy
| | - Nichola Laforgia
- Neonatologia e Terapia Intensiva Neonatale, University of Bari, Bari, Italy
| | - Enikő Mózes
- Perinatal Intensive Care Unit, Department of Obstetrics and Gynaecology, Semmelweis University, Budapest, Hungary
| | - Ketil Størdal
- Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Tobias Strunk
- Neonatal Directorate, Child and Adolescent Health Service, King Edward Memorial Hospital, Perth, Western, Australia
| | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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