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Aljarbou A, Cuello C, Leslie ATFS. Short course of intravenous antibiotics in the treatment of uncomplicated proven neonatal bacterial sepsis: A systematic review. Acta Paediatr 2024; 113:56-66. [PMID: 37702222 DOI: 10.1111/apa.16972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023]
Abstract
AIM To evaluate the efficacy and harms of a short (7-10 days) compared with a standard (10-14 days) duration of antibiotics in culture-proven neonatal sepsis for reducing all-cause mortality, treatment failure and duration of hospitalisation. METHODS Medline, EMBASE and Cochrane CENTRAL were searched for randomised trials. RESULTS We included five studies, all conducted in India (447 infants with a gestational age greater than 32 weeks). Except for one study, all studies were at high risk of bias. All-cause mortality was reported in three studies with only one death reported in the standard duration regimen arm (243 patients, very low certainty). A meta-analysis showed no evidence of the effect on treatment failure (RR of 1.47 [95% CI 0.48-4.50], 440 patients, five studies, very low certainty) of short-term antibiotics. Short-term antibiotic regimen shortened the duration of hospitalisation by 4 days (mean difference of -4.04 days [95% CI -5.47 to -2.61]; 4 studies; 371 patients; very low certainty). CONCLUSION Among studies focused on infants born with a gestational age greater than 32 weeks, short-term administration of antibiotics may shorten the duration of hospitalisation, but the evidence is very uncertain. The evidence on other predefined outcomes is very uncertain to draw definite conclusions.
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Affiliation(s)
- Alanoud Aljarbou
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Carlos Cuello
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Cochrane Canada & MacGRADE Centres, Hamilton, Ontario, Canada
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2
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Islam K, Khatun N, Das K, Paul S, Ghosh T, Nayek K. Ten- vs. 14-day antibiotic therapy for culture-positive neonatal sepsis. J Trop Pediatr 2023; 69:fmad036. [PMID: 37986651 DOI: 10.1093/tropej/fmad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND Neonatal sepsis is a major determinant of neonatal mortality. There is a scarcity of evidence-based guidelines for the duration of antibiotics in culture-positive sepsis. OBJECTIVES The aim of this study was to compare the efficacy of 10- and 14-day antibiotic therapies in the management of culture-positive neonatal sepsis. METHODS This randomized controlled trial was conducted in the neonatal intensive care unit of a tertiary care center among the neonates suffering from culture-positive sepsis (with signs of clinical remission on day 9 of antibiotic) between January 2023 and May 2023. Newborns with major congenital anomaly, deep-seated infections, multi-organ dysfunction, associated fungal infections/infection by multiple organisms and severe birth asphyxia were excluded. Two hundred and thirty-four newborns were randomized into two groups-study (received 10 days of antibiotics) and control (received 14 days of antibiotics). Treatment failure, hospital stay and adverse effects were compared between the two groups. p < 0.05 was taken as the limit of statistical significance. RESULTS Median [interquartile range (IQR)] birth weight and gestational age of the study population (53.8% boys) were 2.424 kg (IQR: 2.183-2.695) and 37.3 weeks (IQR: 35.5-38.1), respectively. Acinetobacter was the most commonly isolated species (56, 23.9%). The baseline characteristics of both groups were almost similar. Treatment failure was similar in the study and control groups (3.8% vs. 1.7%, p = 0.40), with a shorter hospital stay [median (IQR): 14 (13-16) vs. 18 (17-19) days, p < 0.001]. CONCLUSION Ten-day antibiotic therapy was comparable with 14-day antibiotic therapy in efficacy, with a shorter duration of hospital stay and without any significant increase in adverse effects.
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Affiliation(s)
- Kamirul Islam
- Department of Pediatrics, Burdwan Medical College, Burdwan 713104, West Bengal, India
| | - Nazima Khatun
- Department of Anesthesiology, Burdwan Medical College, Burdwan 713104, West Bengal, India
| | - Kuntalkanti Das
- Department of Pediatrics, Burdwan Medical College, Burdwan 713104, West Bengal, India
| | - Sudipto Paul
- Department of Pediatrics, Burdwan Medical College, Burdwan 713104, West Bengal, India
| | - Taraknath Ghosh
- Department of Pediatrics, Burdwan Medical College, Burdwan 713104, West Bengal, India
| | - Kaustav Nayek
- Department of Pediatrics, Burdwan Medical College, Burdwan 713104, West Bengal, India
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3
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Perez K, Puia-Dumitrescu M, Comstock BA, Wood TR, Mayock DE, Heagerty PJ, Juul SE. Patterns of Infections among Extremely Preterm Infants. J Clin Med 2023; 12:2703. [PMID: 37048786 PMCID: PMC10095151 DOI: 10.3390/jcm12072703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/30/2023] [Accepted: 04/02/2023] [Indexed: 04/08/2023] Open
Abstract
Infections remain a leading cause of neonatal death, especially among the extremely preterm infants. To evaluate the incidence, pathogenesis, and in-hospital outcomes associated with sepsis among hospitalized extremely preterm infants born at 24-0/7 to 27-6/7 weeks of gestation, we designed a post hoc analysis of data collected prospectively during the Preterm Epo Neuroprotection (PENUT) Trial, NCT #01378273. We analyzed culture positive infection data, as well as type and duration of antibiotic course and described their association with in-hospital morbidities and mortality. Of 936 included infants, 229 (24%) had at least one positive blood culture during their hospitalization. Early onset sepsis (EOS, ≤3 days after birth) occurred in 6% of the infants, with Coagulase negative Staphylococci (CoNS) and Escherichia Coli the most frequent pathogens. Late onset sepsis (LOS, >day 3) occurred in 20% of the infants. Nearly all infants were treated with antibiotics for presumed sepsis at least once during their hospitalization. The risk of confirmed or presumed EOS was lower with increasing birthweight. Confirmed EOS had no significant association with in-hospital outcomes or death while LOS was associated with increased risk of necrotizing enterocolitis and death. Extremely premature infants with presumed sepsis as compared to culture positive sepsis had lower rates of morbidities. In conclusion, the use of antibiotics for presumed sepsis remains much higher than confirmed infection rates. Ongoing work exploring antibiotic stewardship and presumed, culture-negative sepsis in extremely preterm infants is needed.
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Affiliation(s)
- Krystle Perez
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
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4
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Rallis D, Giapros V, Serbis A, Kosmeri C, Baltogianni M. Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis. Antibiotics (Basel) 2023; 12:antibiotics12030508. [PMID: 36978375 PMCID: PMC10044400 DOI: 10.3390/antibiotics12030508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Antibiotics are the most frequently prescribed drugs in neonatal intensive care units (NICUs) due to the severity of complications accompanying neonatal sepsis. However, antimicrobial drugs are often used inappropriately due to the difficulties in diagnosing sepsis in the neonatal population. The reckless use of antibiotics leads to the development of resistant strains, rendering multidrug-resistant pathogens a serious problem in NICUs and a global threat to public health. The aim of this narrative review is to provide a brief overview of neonatal sepsis and an update on the data regarding indications for antimicrobial therapy initiation, current guidance in the empirical antimicrobial selection and duration of therapy, and indications for early discontinuation.
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Affiliation(s)
- Dimitrios Rallis
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
- Correspondence: ; Tel.: +30-(26)-51099326
| | - Anastasios Serbis
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Chrysoula Kosmeri
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
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5
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Pong S, Fowler RA, Murthy S, Pernica JM, Gilfoyle E, Fontela P, Rishu AH, Mitsakakis N, Hutchison JS, Science M, Seto W, Jouvet P, Daneman N. Antimicrobial treatment duration for uncomplicated bloodstream infections in critically ill children: a multicentre observational study. BMC Pediatr 2022; 22:179. [PMID: 35382774 PMCID: PMC8981828 DOI: 10.1186/s12887-022-03219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background Bloodstream infections (BSIs) cause significant morbidity and mortality in critically ill children but treatment duration is understudied. We describe the durations of antimicrobial treatment that critically ill children receive and explore factors associated with treatment duration. Methods We conducted a retrospective observational cohort study in six pediatric intensive care units (PICUs) across Canada. Associations between treatment duration and patient-, infection- and pathogen-related characteristics were explored using multivariable regression analyses. Results Among 187 critically ill children with BSIs, the median duration of antimicrobial treatment was 15 (IQR 11–25) days. Median treatment durations were longer than two weeks for all subjects with known sources of infection: catheter-related 16 (IQR 11–24), respiratory 15 (IQR 11–26), intra-abdominal 20 (IQR 14–26), skin/soft tissue 17 (IQR 15–33), urinary 17 (IQR 15–35), central nervous system 33 (IQR 15–46) and other sources 29.5 (IQR 15–55) days. When sources of infection were unclear, the median duration was 13 (IQR 10–16) days. Treatment durations varied widely within and across PICUs. In multivariable linear regression, longer treatment durations were associated with severity of illness (+ 0.4 days longer [95% confidence interval (CI), 0.1 to 0.7, p = 0.007] per unit increase in PRISM-IV) and central nervous system infection (+ 17 days [95% CI, 6.7 to 27.4], p = 0.001). Age and pathogen type were not associated with treatment duration. Conclusions Most critically ill children with BSIs received at least two weeks of antimicrobial treatment. Further study is needed to determine whether shorter duration therapy would be effective for selected critically ill children. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03219-z.
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Affiliation(s)
- Sandra Pong
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Srinivas Murthy
- Department of Pediatrics, Division of Critical Care, University of British Columbia, Vancouver, BC, Canada.,Research Institute, BC Children's Hospital, Vancouver, BC, Canada
| | - Jeffrey M Pernica
- Division of Infectious Diseases, McMaster University, Hamilton, ON, Canada
| | - Elaine Gilfoyle
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia Fontela
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.,Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Asgar H Rishu
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nicholas Mitsakakis
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - James S Hutchison
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michelle Science
- Division of Infectious Diseases, Department of Paediatric Medicine, The Hospital for Children, Toronto, ON, Canada
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, Sainte-Justine Hospital University Center, Montreal, QC, Canada.,Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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6
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Reddy A, Sathenahalli V, Shivanna N, Benakappa N, Bandiya P. Ten Versus 14 Days of Antibiotic Therapy in Culture-Proven Neonatal Sepsis: A Randomized, Controlled Trial. Indian J Pediatr 2022; 89:339-342. [PMID: 34097231 DOI: 10.1007/s12098-021-03794-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare the efficacy of 10 d versus 14 d of antibiotic therapy in neonates with culture-positive sepsis. METHODS Neonates with culture-positive sepsis were randomized to either 10-d or 14-d antibiotic therapy. These neonates were followed up to 28 d after discharge for treatment failure. Primary outcome of the study was treatment failure which was defined as readmission to the NICU within 4 wk of discharge with blood culture growing same organism with similar antibiogram or any readmission with signs of sepsis with negative blood culture. RESULTS A total of 70 neonates were randomized to receive either 10 d (n = 35) or 14 d (n = 35) of antibiotic therapy. Gram-negative infections were encountered in majority of the neonates. Treatment failure occurred in 1 neonate in 10-d group and none in 14-d group. The duration of hospital stay was significantly less in 10-d group as compared to 14-d group (16 d vs. 23 d, p < 0.01). CONCLUSIONS Ten days of antibiotics in neonates with culture-positive sepsis, who have achieved clinical and microbiologic remission at day 7, is noninferior to 14 d of therapy. Larger adequately powered trials will address this issue with certainty.
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Affiliation(s)
- Asha Reddy
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Karnataka, 560029, Bangalore, India
| | - Veeraraja Sathenahalli
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Karnataka, 560029, Bangalore, India.
| | - Niranjan Shivanna
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Karnataka, 560029, Bangalore, India
| | - Naveen Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Karnataka, 560029, Bangalore, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
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7
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Duration of Antibiotic Therapy in Neonatal Gram-negative Bacterial Sepsis-10 Days Versus 14 Days: A Randomized Controlled Trial. Pediatr Infect Dis J 2022; 41:156-160. [PMID: 34890377 DOI: 10.1097/inf.0000000000003314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Optimal duration of antibiotic therapy in Gram-negative bacterial (GNB) sepsis in non-VLBW infants has not been specifically evaluated in previous studies. METHODS This was an open labeled noninferiority randomized controlled trial. Non-VLBW infants with GNB sepsis without meningitis whose blood culture were sterile after day 7 of treatment and who were in clinical remission on day 9 of appropriate antibiotic were randomized to short duration (SDR) group and long duration (LDR) group. Infants in SDR group and LDR group received antibiotic therapy for 10 days and 14 days respectively. Primary objective was to compare treatment failure. Secondary objectives were to compare duration of hospitalization, complications of intravenous (IV) therapy and its duration, episodes of new-onset sepsis and all-cause mortality. RESULTS Of 222 infants with GNB sepsis, 58 eligible infants were randomized in each group and 113 of these were analyzed. There was no difference in proportion of infants with multidrug-resistant (MDR) organism in SDR versus LDR group [33(60%) versus 32(55.1%) (P = 0.84)]. There were no treatment failures in either group. Median (IQR) duration of hospital stay was higher in LDR group as compared with SDR group: 20(18, 23) versus 16(13, 20) days (P < 0.001). Infants in LDR group required IV therapy for a longer duration as compared with SDR group mean (SD): 15.2(1.2) versus 10.9(0.8) days (P < 0.001). Median (IQR) episodes of extravasation were higher in LDR group: 5(4.7) versus 3(2.3) (P < 0.001). There was no difference in episodes of phlebitis and hematoma. No infants had died on follow up. CONCLUSION In suitably selected non-VLBW infants with Gram-negative sepsis, 10 days therapy is noninferior to 14 days therapy.
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8
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Neonatal sepsis: a systematic review of core outcomes from randomised clinical trials. Pediatr Res 2022; 91:735-742. [PMID: 34997225 PMCID: PMC9064797 DOI: 10.1038/s41390-021-01883-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/23/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The lack of a consensus definition of neonatal sepsis and a core outcome set (COS) proves a substantial impediment to research that influences policy and practice relevant to key stakeholders, patients and parents. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In the included studies, the described outcomes were extracted in accordance with the provisions of the Core Outcome Measures in Effectiveness Trials (COMET) handbook and registered. RESULTS Among 884 abstracts identified, 90 randomised controlled trials (RCTs) were included in this review. Only 30 manuscripts explicitly stated the primary and/or secondary outcomes. A total of 88 distinct outcomes were recorded across all 90 studies included. These were then assigned to seven different domains in line with the taxonomy for classification proposed by the COMET initiative. The most frequently reported outcome was survival with 74% (n = 67) of the studies reporting an outcome within this domain. CONCLUSIONS This systematic review constitutes one of the initial phases in the protocol for developing a COS in neonatal sepsis. The paucity of standardised outcome reporting in neonatal sepsis hinders comparison and synthesis of data. The final phase will involve a Delphi Survey to generate a COS in neonatal sepsis by consensus recommendation. IMPACT This systematic review identified a wide variation of outcomes reported among published RCTs on the management of neonatal sepsis. The paucity of standardised outcome reporting hinders comparison and synthesis of data and future meta-analyses with conclusive recommendations on the management of neonatal sepsis are unlikely. The final phase will involve a Delphi Survey to determine a COS by consensus recommendation with input from all relevant stakeholders.
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10
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Dutta S, Nangia S, Jajoo M, Gathwala G, Nesargi S, Sundaram M, Kumar P, Saili A, Kumar D, Dalal P, Suman Rao PN, Shanmugam R, Ray P, Randhawa VS, Saigal K, Sharma M, Nagaraj S, Radhakrishnan D. Comparison of efficacy of a 7-day versus a 14-day course of intravenous antibiotics in the treatment of uncomplicated neonatal bacterial sepsis: study protocol of a randomized controlled non-inferiority trial. Trials 2021; 22:859. [PMID: 34844643 PMCID: PMC8628047 DOI: 10.1186/s13063-021-05785-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a global public health problem. There is no consensus regarding the optimum duration of antibiotics for culture-proven neonatal sepsis. Published randomized controlled trials (RCTs) comparing shorter versus longer courses of antibiotics provide low-quality evidence with serious risk of bias. We hypothesized that among neonates with uncomplicated culture-proven sepsis, antibiotic duration of 7 days is not inferior to 14 days. METHODS This is a multi-centric, parallel-group, stratified, block-randomized, active-controlled, non-inferiority trial with outcome assessment blinded. Stratification is by center and birth weight. Neonates weighing ≥1000 g at birth, with blood-culture-proven sepsis (barring Staphylococcus aureus and fungi), without conditions warranting > 14 days antibiotics, and who clinically remit, are enrolled in the RCT on day 7 of administration of sensitive antibiotics. They are randomly allocated to no further antibiotics (intervention arm: total 7 days) or 7 more days of the same antibiotics (control arm: total 14 days). Allocation is concealed by opaque, sealed envelopes. The primary outcome is "definite or probable relapse" within 21 days after antibiotic completion. Secondary outcomes include definite and probable relapses at various timepoints until day 35 post-randomization, secondary infections, and adverse events. The neonatologist adjudicating probable relapses and lab personnel are blinded. Three hundred fifty subjects will be recruited in each arm, assuming a non-inferiority margin of 7%, one-sided alpha error 5%, and power of 90%. Analysis will be per protocol and by intention-to-treat. An independent Data Safety Monitoring Board monitors adverse events and will perform one interim analysis when 50% of expected primary outcomes have occurred or 50% of subjects have completed follow-up, whichever is earlier. O'Brien-Fleming criteria will be used to stop for mid-term benefit and Pocock's to stop for mid-term harm. A priori subgroup analyses are planned by birth weight categories, gram-stain status of pathogens, and radiological pneumonia. DISCUSSION This trial will provide evidence to guide practice regarding optimum duration of antibiotics for culture-proven neonatal bacterial sepsis. If a 7-day regime is proved to be non-inferior to a 14-day regime, it is likely to reduce hospital stay, costs, adverse effects of drugs, and nosocomial infections. TRIAL REGISTRATION Clinical Trials Registry India CTRI/2017/09/009743 . Registered on 13 September 2017.
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Affiliation(s)
- Sourabh Dutta
- Neonatology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Sushma Nangia
- Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi, India
| | - Mamta Jajoo
- Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Geeta Gathwala
- Postgraduate Institute of Medical Sciences, Rohtak, India
| | | | | | - Praveen Kumar
- Neonatology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arvind Saili
- Lady Hardinge Medical College & Kalawati Saran Children's Hospital, New Delhi, India
| | - Dipti Kumar
- Chacha Nehru Bal Chikitsalaya, New Delhi, India
| | - Poonam Dalal
- Postgraduate Institute of Medical Sciences, Rohtak, India
| | - P N Suman Rao
- St John's Medical College and Hospital, Bengaluru, India
| | - Ramya Shanmugam
- Institute of Child Health, Madras Medical College, Chennai, India
| | - Pallab Ray
- Neonatology Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Madhu Sharma
- Postgraduate Institute of Medical Sciences, Rohtak, India
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11
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Korang SK, Safi S, Nava C, Gordon A, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013837. [PMID: 33998666 PMCID: PMC8127574 DOI: 10.1002/14651858.cd013837.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Possibly due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units. The last Cochrane Review was updated in 2004. Given the clinical importance, an updated systematic review assessing the effects of different antibiotic regimens for early-onset neonatal sepsis is needed. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for early-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2020, Issue 8); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for early-onset neonatal sepsis. We included participants from birth to 72 hours of life at randomisation. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (865 participants). All trials were at high risk of bias. The certainty of the evidence according to GRADE was very low. The included trials assessed five different comparisons of antibiotics. We did not conduct any meta-analyses due to lack of relevant data. Of the five included trials one trial compared ampicillin plus gentamicin with benzylpenicillin plus gentamicin; one trial compared piperacillin plus tazobactam with amikacin; one trial compared ticarcillin plus clavulanic acid with piperacillin plus gentamicin; one trial compared piperacillin with ampicillin plus amikacin; and one trial compared ceftazidime with benzylpenicillin plus gentamicin. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. Large RCTs assessing different antibiotic regimens in early-onset neonatal sepsis with low risk of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Adrienne Gordon
- Neonatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Korang SK, Safi S, Nava C, Greisen G, Gupta M, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013836. [PMID: 33998665 PMCID: PMC8127057 DOI: 10.1002/14651858.cd013836.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units, and observational studies in high-income countries suggest that 83% to 94% of newborns treated with antibiotics for suspected sepsis have negative blood cultures. The last Cochrane Review was updated in 2005. There is a need for an updated systematic review assessing the effects of different antibiotic regimens for late-onset neonatal sepsis. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for late-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2021, Issue 3); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for late-onset neonatal sepsis. We included participants older than 72 hours of life at randomisation, suspected or diagnosed with neonatal sepsis, meningitis, osteomyelitis, endocarditis, or necrotising enterocolitis. We excluded trials that assessed treatment of fungal infections. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (580 participants). All trials were at high risk of bias, and had very low-certainty evidence. The five included trials assessed five different comparisons of antibiotics. We did not conduct a meta-analysis due to lack of relevant data. Of the five included trials one trial compared cefazolin plus amikacin with vancomycin plus amikacin; one trial compared ticarcillin plus clavulanic acid with flucloxacillin plus gentamicin; one trial compared cloxacillin plus amikacin with cefotaxime plus gentamicin; one trial compared meropenem with standard care (ampicillin plus gentamicin or cefotaxime plus gentamicin); and one trial compared vancomycin plus gentamicin with vancomycin plus aztreonam. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. RCTs assessing different antibiotic regimens in late-onset neonatal sepsis with low risks of bias are warranted.
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Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Arakawa S, Kasai M, Kawai S, Sakata H, Mayumi T. The JAID/JSC guidelines for management of infectious diseases 2017 - Sepsis and catheter-related bloodstream infection. J Infect Chemother 2021; 27:657-677. [PMID: 33558043 DOI: 10.1016/j.jiac.2019.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 10/28/2019] [Accepted: 11/29/2019] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Hyogo Prefectural Kobe Children's Hospital, Hyogo, Japan
| | - Shin Kawai
- The Department of General Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Hiroshi Sakata
- Department of Pediatrics, Asahikawa Kosei Hospital, Hokkaido, Japan
| | - Toshihiko Mayumi
- Department of Emergency and Critical Care Medicine,University of Occupational and Environmental Health, Fukuoka, Japan
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Raba AA, O'Sullivan A, Miletin J. Pathogenesis of necrotising enterocolitis: The impact of the altered gut microbiota and antibiotic exposure in preterm infants. Acta Paediatr 2021; 110:433-440. [PMID: 32876963 DOI: 10.1111/apa.15559] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/05/2020] [Accepted: 08/26/2020] [Indexed: 12/26/2022]
Abstract
Necrotising enterocolitis (NEC) is a devastating condition with high morbidity and mortality seen predominately in preterm infants. Multiple factors are associated with the pathogenesis of NEC. The widespread use of antibiotics in the neonatal intensive care unit might play a role in the pathogenesis of NEC in preterm infants. This review provides a summary on the intestinal microbiota in preterm infants with a focus on how antibiotic exposure may reduce the biodiversity of the intestinal microbiota and may predispose preterm infants to NEC. CONCLUSION: Prolonged antibiotic therapy has been suggested as a risk factor for the development of NEC in preterm infants.
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Affiliation(s)
- Ali Ahmed Raba
- UCD School of Medicine and Medical Sciences Dublin Ireland
- Coombe Women and Infants University Hospital Dublin Ireland
| | | | - Jan Miletin
- UCD School of Medicine and Medical Sciences Dublin Ireland
- Coombe Women and Infants University Hospital Dublin Ireland
- Institute for the Care of Mother and Child Prague Czech Republic
- 3rd School of Medicine Charles University Prague Czech Republic
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15
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Audit of Antibiotic Prescribing Practices for Neonatal Sepsis and Measurement of Outcome in New Born Unit at Kenyatta National Hospital. Int J Pediatr 2019; 2019:7930238. [PMID: 31182965 PMCID: PMC6512059 DOI: 10.1155/2019/7930238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 04/01/2019] [Indexed: 01/30/2023] Open
Abstract
Background Neonatal sepsis is a leading cause of morbidity and mortality globally. A high index of suspicion is required since features of sepsis are nonspecific. Auditing of antibiotic use is necessary to reduce misuse and minimise development of antibiotic resistance. Objectives To assess the antibiotic prescribing practices in NBU at KNH against recommended Kenyan guidelines for neonatal sepsis. In addition, outcome within 7 days was described. Methods This was a prospective audit of 320 neonates over a 2-month period at NBU of KNH. Data were collected using a structured questionnaire, stored in MS-EXCEL, and analysed using STATA. Results Documentation of perinatal risk factors and clinical features at admission and at the time of change of antibiotics was very poor. The rate of investigations to confirm infection was very low. Blood cultures were done only in 13 (4%) neonates on admission, while complete blood count and C reactive protein were done in 224 (70%) and 198 (62%), respectively. Appropriate antibiotics as per the Kenyan guidelines were prescribed in 313 (97.8%) of neonates on admission. However, these were not stopped at 48-72 hours for the 148 (53.62%) who had improved. Overall mortality was high in neonates at 80 (25%). Majority (55%) died within 48 hours. Mortality was high among preterm neonates; 70 (43.8%) died out of 160. Conclusion Overall documentation and investigations to confirm infection was poor. The continuation of antibiotics was inappropriate. Overall mortality was high especially in the first 48 hours of admission. To improve documentation, availability of a checklist on admission is recommended.
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Rational Use of Antibiotics in Neonates: Still in Search of Tailored Tools. Healthcare (Basel) 2019; 7:healthcare7010028. [PMID: 30781454 PMCID: PMC6473895 DOI: 10.3390/healthcare7010028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/31/2019] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
Rational medicine use in neonates implies the prescription and administration of age-appropriate drug formulations, selecting the most efficacious and safe dose, all based on accurate information on the drug and its indications in neonates. This review illustrates that important uncertainties still exist concerning the different aspects (when, what, how) of rational antibiotic use in neonates. Decisions when to prescribe antibiotics are still not based on robust decision tools. Choices (what) on empiric antibiotic regimens should depend on the anticipated pathogens, and the available information on the efficacy and safety of these drugs. Major progress has been made on how (beta-lactam antibiotics, aminoglycosides, vancomycin, route and duration) to dose. Progress to improve rational antibiotic use necessitates further understanding of neonatal pharmacology (short- and long-term safety, pharmacokinetics, duration and route) and the use of tailored tools and smarter practices (biomarkers, screening for colonization, and advanced therapeutic drug monitoring techniques). Implementation strategies should not only facilitate access to knowledge and guidelines, but should also consider the most effective strategies (‘skills’) and psychosocial aspects involved in the prescription process: we should be aware that both the decision not to prescribe as well as the decision to prescribe antibiotics is associated with risks and benefits.
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Comparison of Four Days Versus Seven Days Duration of Antibiotic Therapy for Neonatal Pneumonia: A Randomized Controlled Trial. Indian J Pediatr 2018; 85:963-967. [PMID: 29781043 DOI: 10.1007/s12098-018-2708-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To compare the effect of 4 day course (study group) with 7 day course (control group) of antibiotic treatment in neonatal pneumonia, on treatment success rate. METHODS This randomized controlled trial was conducted in a tertiary teaching hospital. Seventy, term and near-term neonates with pneumonia who had clinical remission by 48 h of antibiotic therapy were included. The neonates were randomized to receive a total of 4 d of antibiotics (Group 1) or 7 d of antibiotics (Group 2). The outcome measure was treatment failure in each group within 3 d of discharge. RESULTS The treatment success rate of both the groups was 100%. There was a significant reduction in the duration of hospital stay (p < 0.001), antibiotic usage (p < 0.001), and cost (p < 0.001) in the 4 d group. On follow up till 28 d of enrollment, no infective morbidity was found in either group. CONCLUSIONS For term and near-term neonates who become clinically asymptomatic within 48 h of antibiotic therapy, 4 d of antibiotic therapy is as effective and safe as 7 d of antibiotic therapy, with significant reduction in hospital stay, antibiotic usage and cost.
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Rohatgi S, Dewan P, Faridi MMA, Kumar A, Malhotra RK, Batra P. Seven versus 10 days antibiotic therapy for culture-proven neonatal sepsis: A randomised controlled trial. J Paediatr Child Health 2017; 53:556-562. [PMID: 28398692 DOI: 10.1111/jpc.13518] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 11/09/2016] [Accepted: 12/03/2016] [Indexed: 02/05/2023]
Abstract
AIM Optimal duration of parenteral antibiotics for treating neonatal sepsis ranges from 7-14 days. We compared the efficacy of 7 versus 10 days duration of intravenous antibiotics for neonatal septicaemia. METHODS We randomised blood culture-proven septic neonates (≥32 weeks and birth weight ≥1.5 kg) to receive either 7 or 10 days duration of intravenous antibiotics. We followed up neonates upto 28 days after stopping antibiotics for treatment failure defined by reappearance of clinical sepsis with a blood culture growing the same organism as cultured earlier, or in the absence of a positive culture, the presence of C-reactive protein and as adjudicated by an expert committee. RESULTS A total of 132 neonates were randomised to receive either 7 (n = 66) or 10 (n = 66) days duration of antibiotic therapy. Out of 128 neonates (64 per group) followed up, two (one per group) were regarded as 'treatment failure', and two were labelled as fresh episodes of sepsis (both in 10-day group). The risk (95% confidence interval) for treatment failure in the 7-day group was (1.0 (0.064-15.644) was not significantly higher. Neonates in both groups had comparable need for oxygen, inotropic support and blood products, duration of oxygen therapy and time to attainment of full feeds. The duration of hospitalisation was significantly longer in the 10-day group. CONCLUSION A 7-day course of intravenous antibiotics may be sufficient to treat neonatal sepsis with the advantage of shorter hospital stay, but a larger meta-analysis would be required to state this with a degree of certainty.
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Affiliation(s)
- Smriti Rohatgi
- Department of Pediatrics, University College of Medical Sciences, Delhi, India
| | - Pooja Dewan
- Department of Pediatrics, University College of Medical Sciences, Delhi, India
| | | | - Ashwani Kumar
- Department of Microbiology, University College of Medical Sciences, Delhi, India
| | - Rajeev Kumar Malhotra
- Department of Biostatistics and Medical Informatics, University College of Medical Sciences, Delhi, India
| | - Prerna Batra
- Department of Pediatrics, University College of Medical Sciences, Delhi, India
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Folgori L, Bielicki J, Ruiz B, Turner MA, Bradley JS, Benjamin DK, Zaoutis TE, Lutsar I, Giaquinto C, Rossi P, Sharland M. Harmonisation in study design and outcomes in paediatric antibiotic clinical trials: a systematic review. THE LANCET. INFECTIOUS DISEASES 2016; 16:e178-e189. [PMID: 27375212 DOI: 10.1016/s1473-3099(16)00069-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/15/2016] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
There is no global consensus on the conduct of clinical trials in children and neonates with complicated clinical infection syndromes. No comprehensive regulatory guidance exists for the design of antibiotic clinical trials in neonates and children. We did a systematic review of antibiotic clinical trials in complicated clinical infection syndromes (including bloodstream infections and community-acquired pneumonia) in children and neonates (0-18 years) to assess whether standardised European Medicines Agency (EMA) and US Food and Drug Administration (FDA) guidance for adults was used in paediatrics, and whether paediatric clinical trials applied consistent definitions for eligibility and outcomes. We searched MEDLINE, Cochrane CENTRAL databases, and ClinicalTrials.gov between Jan 1, 2000, and Nov 18, 2015. 82 individual studies met our inclusion criteria. The published studies reported on an average of 66% of CONSORT items. Study design, inclusion and exclusion criteria, and endpoints varied substantially across included studies. The comparison between paediatric clinical trials and adult EMA and FDA guidance highlighted that regulatory definitions are only variably applicable and used at present. Absence of consensus for paediatric antibiotic clinical trials is a major barrier to harmonisation in research and translation into clinical practice. To improve comparison of therapies and strategies, international collaboration among all relevant stakeholders leading to harmonised case definitions and outcome measures is needed.
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Affiliation(s)
- Laura Folgori
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK; Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
| | - Beatriz Ruiz
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Mark A Turner
- University of Liverpool, Institute of Translational Medicine, Department of Women's and Children's Health, Crown Street, Liverpool, UK
| | - John S Bradley
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA; Rady Children's Hospital San Diego, San Diego, CA, USA
| | | | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paolo Rossi
- University Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Rome, Italy
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK.
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Mathur NB, Kharod P, Kumar S. Evaluation of duration of antibiotic therapy in neonatal bacterial meningitis: a randomized controlled trial. J Trop Pediatr 2015; 61:119-25. [PMID: 25681965 DOI: 10.1093/tropej/fmv002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To compare the effect of 10 days versus 14 days of antibiotic therapy in neonatal meningitis on treatment failure rate. METHODS The study was a randomized controlled trial conducted at a referral neonatal unit. The participants were 70 neonates with meningitis randomized to receive 10 days (study group) or 14 days (control group) of antibiotics. The primary outcome measure studied was treatment failure in each group within 28 days of enrolment. RESULTS None of the neonates among either of the groups had occurrence of meningitis during follow-up. Occurrence of sepsis was observed after discharge in three neonates in the control group and none in the study group. Brainstem-evoked response audiometry was abnormal in one neonate in the study group. Adverse effects of drugs and neurological deficits were not observed in the study population. CONCLUSIONS Short course of antibiotic therapy (10 days) is effective, with potential benefits of shorter hospital stay.
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Affiliation(s)
- N B Mathur
- Department of Neonatology, Maulana Azad Medical College, New Delhi, India
| | - Prarthana Kharod
- Department of Neonatology, Maulana Azad Medical College, New Delhi, India
| | - Surinder Kumar
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
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Abstract
Neonatal sepsis is the third leading cause of neonatal mortality and a major public health problem, especially in developing countries. Although recent medical advances have improved neonatal care, many challenges remain in the diagnosis and management of neonatal infections. The diagnosis of neonatal sepsis is complicated by the frequent presence of noninfectious conditions that resemble sepsis, especially in preterm infants, and by the absence of optimal diagnostic tests. Since neonatal sepsis is a high-risk disease, especially in preterm infants, clinicians are compelled to empirically administer antibiotics to infants with risk factors and/or signs of suspected sepsis. Unfortunately, both broad-spectrum antibiotics and prolonged treatment with empirical antibiotics are associated with adverse outcomes and increase antimicrobial resistance rates. Given the high incidence and mortality of sepsis in preterm infants and its long-term consequences on growth and development, efforts to reduce the rates of infection in this vulnerable population are one of the most important interventions in neonatal care. In this review, we discuss the most common questions and challenges in the diagnosis and management of neonatal sepsis, with a focus on developing countries.
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Affiliation(s)
- Alonso Zea-Vera
- Instituto de Medicina Tropical “Alexander von Humbolt” and Pediatrics, Universidad Peruana Cayetano Heredia, Lima, Lima 31, Peru
| | - Theresa J. Ochoa
- Instituto de Medicina Tropical “Alexander von Humbolt” and Pediatrics, Universidad Peruana Cayetano Heredia, Lima, Lima 31, Peru,Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center, School of Public Health, Houston, Texas, 77225, USA
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Park SH, Milstone AM, Diener-West M, Nussenblatt V, Cosgrove SE, Tamma PD. Short versus prolonged courses of antibiotic therapy for children with uncomplicated Gram-negative bacteraemia. J Antimicrob Chemother 2013; 69:779-85. [DOI: 10.1093/jac/dkt424] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Tzialla C, Borghesi A, Perotti GF, Garofoli F, Manzoni P, Stronati M. Use and misuse of antibiotics in the neonatal intensive care unit. J Matern Fetal Neonatal Med 2012; 25 Suppl 4:35-7. [DOI: 10.3109/14767058.2012.714987] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Choice and duration of antimicrobial therapy for neonatal sepsis and meningitis. Int J Pediatr 2011; 2011:712150. [PMID: 22164179 PMCID: PMC3228399 DOI: 10.1155/2011/712150] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 10/04/2011] [Indexed: 12/26/2022] Open
Abstract
Neonatal sepsis is associated with increased mortality and morbidity including neurodevelopmental impairment and prolonged hospital stay. Signs and symptoms of sepsis are nonspecific, and empiric antimicrobial therapy is promptly initiated after obtaining appropriate cultures. However, many preterm and low birth weight infants who do not have infection receive antimicrobial agents during hospital stay. Prolonged and unnecessary use of antimicrobial agents is associated with deleterious effects on the host and the environment. Traditionally, the choice of antimicrobial agents is based on the local policy, and the duration of therapy is decided by the treating physician based on clinical symptoms and blood culture results. In this paper, we discuss briefly the causative organism of neonatal sepsis in both the developed and developing countries. We review the evidence for appropriate choice of empiric antimicrobial agents and optimal duration of therapy in neonates with suspected sepsis, culture-proven sepsis, and meningitis. Moreover, there is significant similarity between the causative organisms for early- and late-onset sepsis in developing countries. The choice of antibiotic described in this paper may be more applicable in developed countries.
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