NICE clinical guideline: antibiotics for the prevention and treatment of early-onset neonatal infection

Diagnostic value of maternal, cord blood and neonatal biomarkers for early-onset sepsis: a systematic review and meta-analysis

BACKGROUND

An accurate diagnosis of early-onset sepsis (EOS) is challenging because of subtle symptoms and the lack of a good diagnostic tool, resulting in considerable antibiotic overtreatment. A biomarker, discriminating between infected and non-infected newborns at an early stage of the disease, could improve EOS prediction. Numerous biomarkers have been tested, but have never been compared directly.

OBJECTIVES

We aimed to provide a comprehensive overview of early biomarkers and their diagnostic value in maternal samples, umbilical cord blood, and neonatal serum.

DATA SOURCES

PubMed-Medline, EMBASE, The Cochrane Library, and Web of Science were searched up to 1 March 2023, without restrictions on publication date, population, or language.

STUDY ELIGIBILITY CRITERIA

Articles describing the diagnostic value of at least one biomarker in the detection of EOS in neonates, independent of gestational age, were included.

ASSESSMENT OF RISK OF BIAS

The QUADAS-2 tool was used to assess study quality.

METHODS OF DATA SYNTHESIS

Three independent researchers assessed the articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Meta-analysis was performed with all manuscripts describing diagnostic accuracy using a random-effects model.

RESULTS

Of 2296 identified articles, 171 reports were included in the systematic review and 69 in the meta-analysis. Literature showed mixed and inconsistent evidence for most biomarkers and sample types, because of a lack of a uniform EOS case definition, small sample sizes, and large heterogeneity between studies. Interesting markers were procalcitonin (pooled sensitivity 79%, 95% CI 71-84%; specificity 91%, 95% CI 83-96%, n = 11) and interleukin (IL)-6 (pooled sensitivity 83%, 95% CI 71-90%; specificity 87%, 95% CI 78-93%, n = 8) in umbilical cord blood and presepsin (pooled sensitivity 82%, 95% CI 62-93%; specificity 86%, 95% CI 73-93%, n = 3) and serum amyloid A (pooled sensitivity 92%, 95% CI 75-98%; specificity 96%, 95% CI 78-99%, n = 4) in neonatal serum. Studies on the combination of biomarkers were scarce.

CONCLUSIONS

A biomarker stand-alone test is currently not reliable for direct antibiotic stewardship in newborns, although several biomarkers show promising initial results. Further research into biomarker combinations could lead to an improved EOS diagnosis, reduce antibiotic overtreatment, and prevent associated health-related problems.

Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis

OBJECTIVE

To assess the impact of publication of UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention and treatment of early-onset infections (EOIs) in neonates (clinical guideline 149 (CG149), published in 2012, and its 2021 update (NG195) on antibiotic use in very preterm infants.

DESIGN

Interrupted time series analysis using data from the National Neonatal Research Database.

SETTING

Neonatal units in England and Wales.

PARTICIPANTS

Infants born at 22-31 weeks' gestation from 1 January 2010 to 31 December 2022 and survived to discharge.

INTERVENTIONS

Publication of CG149 (August 2012) and NG195 (April 2021).

MAIN OUTCOME MEASURES

Measures of antibiotic use, aggregated by month of birth: antibiotic use rate (AUR), the proportion of care days in receipt of at least one antibiotic; percentage of infants who received ≥1 day of antibiotics on days 1-3 for EOI and after day 3 for late-onset infection (LOI); percentage who received ≥1 prolonged antibiotic course ≥5 days for EOI and LOI.

RESULTS

96% of infants received an antibiotic during inpatient stay. AUR declined at publication of CG149, without further impact at NG195 publication. There was no impact of CG149 on the underlying trend in infants receiving ≥1 day antibiotics for EOI or LOI, but post-NG195 the monthly trend began to decline for EOI (-0.20%, -0.26 to -0.14) and LOI (-0.23%, -0.33 to -0.12). Use of prolonged antibiotic courses for EOI and LOI declined at publication of CG149 and for LOI this trend accelerated post-NG195.

CONCLUSIONS

Publications of NICE guidance were associated with reductions in antibiotic use; however neonatal antibiotic exposure remains extremely high.

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

Antibiotic Use in Late Preterm and Full-Term Newborns

Importance

Antibiotic treatment saves lives in newborns with early-onset sepsis (EOS), but unwarranted antibiotic use is associated with resistant bacteria and adverse outcomes later in life. Surveillance is needed to optimize treatment strategies.

Objective

To describe antibiotic use in association with the incidence and mortality from EOS among late-preterm and full-term newborns.

Design, Setting, and Participants

The Sweden Neonatal Antibiotic Use study was a nationwide observational study that included all late-preterm and full-term neonates born from January 1, 2012, to December 31, 2020, in neonatal units of all levels. All hospital live births from 34 weeks' gestation during the study period were included in the study. Data were collected from the Swedish Neonatal Quality Register and the Swedish Medical Birth Register. Data were analyzed from August 2022 to May 2023.

Exposure

Admission for neonatal intensive care during the first week of life.

Main Outcomes and Measures

The main outcomes were the usage of intravenous antibiotics during the first week of life, the duration of antibiotic therapy, the rate of culture-proven EOS, and mortality associated with EOS.

Results

A total of 1 025 515 newborns were included in the study; 19 286 neonates (1.88%; 7686 girls [39.9%]; median [IQR] gestational age, 40 [38-41] weeks; median [IQR] birth weight, 3610 [3140-4030] g) received antibiotics during the first week of life, of whom 647 (3.4%) had EOS. The median (IQR) duration of antibiotic treatment in newborns without EOS was 5 (3-7) days, and there were 113 antibiotic-days per 1000 live births. During the study period there was no significant change in the exposure to neonatal antibiotics or antibiotic-days per 1000 live births. The incidence of EOS was 0.63 per 1000 live births, with a significant decrease from 0.74 in 2012 to 0.34 in 2020. Mortality associated with EOS was 1.39% (9 of 647 newborns) and did not change significantly over time. For each newborn with EOS, antibiotic treatment was initiated in 29 newborns and 173 antibiotic-days were dispensed.

Conclusions and Relevance

This large nationwide study found that a relatively low exposure to antibiotics is not associated with an increased risk of EOS or associated mortality. Still, future efforts to reduce unwarranted neonatal antibiotic use are needed.

Longer duration of initial invasive mechanical ventilation is still a crucial risk factor for moderate-to-severe bronchopulmonary dysplasia in very preterm infants: a multicentrer prospective study

OBJECTIVES

We aimed to evaluate the risk factors for moderate-to-severe bronchopulmonary dysplasia (BPD) and focus on discussing its relationship with the duration of initial invasive mechanical ventilation (IMV) in very preterm neonates less than 32 weeks of gestational age (GA).

METHODS

We performed a prospective cohort study involving infants born at 23-31 weeks of GA who were admitted to 47 different neonatal intensive care unit (NICU) hospitals in China from January 2018 to December 2021. Patient data were obtained from the Sina-northern Neonatal Network (SNN) Database.

RESULTS

We identified 6538 very preterm infants, of whom 49.5% (3236/6538) received initial IMV support, and 12.6% (823/6538) were diagnosed with moderate-to-severe BPD symptoms. The median duration of initial IMV in the moderate-to-severe BPD group was 26 (17-41) days, while in the no or mild BPD group, it was 6 (3-10) days. The incidence rate of moderate-to-severe BPD and the median duration of initial IMV were quite different across different GAs. Multivariable logistic regression analysis showed that the onset of moderate-to-severe BPD was significantly associated with the duration of initial IMV [adjusted odds ratio (AOR): 1.97; 95% confidence interval (CI): 1.10-2.67], late-onset neonatal sepsis (LONS), and patent ductus arteriosus (PDA).

CONCLUSION

In this multicenter cohort study, the duration of initial IMV was still relatively long in very premature infants, and the longer duration of initial IMV accounts for the increased risk of moderate-to-severe BPD.

Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis

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.

Clinical Risk Factors for Early-Onset Sepsis in Neonates: An International Delphi Study

Background

Despite growing evidence, there is still uncertainty about potentially modifiable risk factors for neonatal early-onset sepsis (EOS). This study aimed to identify potential clinical risk factors for EOS based on a literature review and expert opinions.

Methods

A literature search was conducted in PubMed (MEDLINE), Cochrane, Embase, and Scopus databases. Articles in English, published up to May 2021, on clinical risk factors for neonatal EOS were included. Initially, a questionnaire on risk factors for EOS was developed and validated. The fuzzy Delphi method (FDM) was used to formulate the final version of the questionnaire. The validity of the risk factors was assessed using the Chi square test. P<0.05 was considered statistically significant.

Results

In the review phase, 30 risk factors were approved by two neonatologists and included in the FDM phase. In total, 25 risk factors met the consensus criteria and entered the validation phase. During the observational study, 114 neonates (31 with and 83 without EOS) were evaluated for two months. The results of the Chi square test showed that cesarean section was not a significant risk factor for EOS (P=0.862). The need for mechanical ventilation and feed intolerance was observed in about 70% of neonates with EOS, and therefore considered significant risk factors for EOS (P<0.001). Finally, 26 potential clinical risk factors were determined.

Conclusion

Neonatal-related risk factors for EOS were birth weight, one-min Apgar score, and prematurity. Maternal-related risk factors were gestational age and urinary tract infection. Delivery-related risk factors were premature rupture of membranes, chorioamnionitis, and intrapartum fever.

Clinical and laboratory factors associated with neonatal sepsis mortality at a major Vietnamese children's hospital

Sepsis is a major cause of neonatal mortality and children born in low- and middle-income countries (LMICs) are at greater risk of severe neonatal infections than those in higher-income countries. Despite this disparity, there are limited contemporaneous data linking the clinical features of neonatal sepsis with outcome in LMICs. Here, we aimed to identify factors associated with mortality from neonatal sepsis in Vietnam. We conducted a prospective, observational study to describe the clinical features, laboratory characteristics, and mortality rate of neonatal sepsis at a major children's hospital in Ho Chi Minh City. All in-patient neonates clinically diagnosed with probable or culture-confirmed sepsis meeting inclusion criteria from January 2017 to June 2018 were enrolled. We performed univariable analysis and logistic regression to identify factors independently associated with mortality. 524 neonates were recruited. Most cases were defined as late-onset neonatal sepsis and were hospital-acquired (91.4% and 73.3%, respectively). The median (IQR) duration of hospital stay was 23 (13-41) days, 344/524 (65.6%) had a positive blood culture (of which 393 non-contaminant organisms were isolated), and 69/524 (13.2%) patients died. Coagulase-negative staphylococci (232/405; 57.3%), Klebsiella spp. (28/405; 6.9%), and Escherichia coli (27/405; 6.7%) were the most isolated organisms. Sclerema (OR = 11.4), leukopenia <4,000/mm3 (OR = 7.8), thrombocytopenia <100,000/mm3 (OR = 3.7), base excess < -20 mEq/L (OR = 3.6), serum lactate >4 mmol/L (OR = 3.4), extremely low birth weight (OR = 3.2), and hyperglycaemia >180 mg/dL (OR = 2.6) were all significantly (p<0.05) associated with mortality. The identified risk factors can be adopted as prognostic factors for the diagnosis and treatment of neonatal sepsis and enable early risk stratification and interventions appropriate to reduce neonatal sepsis in LMIC settings.

Infections in the NICU: Neonatal sepsis

Neonatal infections remain an important cause of neonatal morbidity and mortality worldwide. Neonatal sepsis is a systemic infection that can be classified as early-onset or late-onset pending the timing of presentation. The pathophysiology and causative pathogens of neonatal sepsis vary, with early-onset sepsis being associated with a vertically transmitted infection from mother to neonate versus late onset sepsis being commonly associated with nosocomial infections. The signs and symptoms of neonatal sepsis mimic those associated with prematurity, making timely diagnosis difficult for treating clinicians. The management of neonatal sepsis is centered around obtaining adequate culture data and initiation of broad-spectrum parenteral antibiotics. Controversies surrounding the management of neonatal sepsis include the administration of empiric antibiotics, given recent clinical studies associating early antibiotic use with clinical sequelae such as late-onset sepsis, necrotizing enterocolitis, and death in the preterm, low-birthweight infant population.

Latency period of PROM at term and the risk of neonatal infectious diseases

To find the risk of time thresholds of PROM for infectious diseases of term neonates. A multi-center prospective cohort study including pregnancies with PROM at term with a single fetus were conducted. Time thresholds of the duration from PROM to delivery were examined in 2-h increments to assess the rates of infectious neonatal diseases. 7019 pregnancies were included in the study. Neonatal pneumonia and sepsis were most frequent infectious diseases in neonates born from mother with PROM at term. Rates of early-onset pneumonia varied significantly when comparing length of time of PROM greater than 16 h vs. less than 16 h (for EOP in 3 days of life, adjusted OR 1.864, 95% CI 1.159 ~ 2.997, p = 0.010; for EOP in 7 days of life, adjusted OR 1.704, 95% CI 1.104 ~ 2.628, p = 0.016). Neonates born from mother of whom the length of time from PROM to delivery ≥ 16 h were at a higher risk of acquiring EOP.

Obstetric Risk Factors and Serological Characteristics of Early-Onset Neonates Bacterial Infections

Purpose

To analyze the obstetric high-risk factors and serological characteristics of early-onset neonatal bacterial infections (EONBI).

Methods

119 neonates with early-onset bacterial infection who were admitted to the neonatal ward of our hospital from October 2020 to December 2021 were recorded as the study group, and 100 neonates without bacterial infection who were admitted during the same period were used as the reference group. Comparative analysis of obstetric high-risk factors and serological characteristics of EONBI.

Results

There was no statistical difference between the two groups in terms of gender and age at admission (P > 0.05). The gestational age and birth weight of newborns in the study group were lower than those in the reference group (P < 0.001). Comparing the maternal factors of EONBI between the two groups, there was no statistical difference in age, number of obstetric inspections, whether to use antibiotics, and mode of delivery (P > 0.05). Univariate analysis showed that preterm birth, unexplained asphyxia, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h were significantly associated with EONBI (P < 0.05); while there was no significant difference between the two groups in the comparison between diabetic mother and child and maternal fever at delivery (P > 0.05). Multifactorial analysis showed that preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h had a good multivariate dependence on EONBI (P < 0.05), while there was no significant association with unexplained asphyxia, diabetic mother and child, and maternal fever at delivery (P > 0.05). The incidence of neonatal temperature >37.9°C was higher in the study group than in the reference group (P < 0.05), and there were no statistical differences in the comparison of other clinical manifestations (P > 0.05). The CRP level of neonates in the study group (47.33 ± 4.14) mg/L was higher than that of the reference group (4.84 ± 1.03) mg/L (P < 0.001). The WBC level of neonates in the study group (5.64 ± 1.18) 10⁹/L was higher than that of the reference group (0.28 ± 0.04) 10⁹/L (P < 0.001). The PCT level of neonates in the study group (5.41 ± 0.85) µg/L was higher than that of the reference group (0.24 ± 0.07) µg/L (P < 0.001).

Conclusion

EONBI is closely associated with several obstetric high-risk factors, including preterm birth, fecal contamination of amniotic fluid, maternal infection during pregnancy, and premature rupture of membranes ≥18 h; EONBI has no specific symptoms and signs, but serum CRP, WBC, and PCT levels are significantly higher than those of newborns without co-infection with bacteria.

Early-onset neonatal sepsis and antibiotic use in Indonesia: a descriptive, cross-sectional study

BACKGROUND

Early diagnosis and prompt antibiotic treatment are crucial to reducing morbidity and mortality of early-onset sepsis (EOS) in neonates. However, this strategy remains challenging due to non-specific clinical findings and limited facilities. Inappropriate antibiotics use is associated with ineffective therapy and adverse outcomes. This study aims to determine the characteristics of EOS and use of antibiotics in the neonatal-intensive care units (NICUs) in Indonesia, informing efforts to drive improvements in the prevention, diagnosis, and treatment of EOS.

METHODS

A descriptive study was conducted based on pre-intervention data of the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Our study population consisted of neonates admitted within 72 h of life to the three participating NICUs. Neonates who presented with three or more clinical signs or laboratory results consistent with sepsis and who received antibiotics for 5 consecutive days were considered to have EOS. Culture-proven EOS was defined as positive blood or cerebrospinal fluid culture. Type and duration of antibiotics used were also documented.

RESULTS

Of 2,509 neonates, 242 cases were suspected of having EOS (9.6%) with culture-proven sepsis in 83 cases (5.0% of neonatal admissions in hospitals with culture facilities). The causative organisms were mostly gram-negative bacteria (85/94; 90.4%). Ampicillin / amoxicillin and amikacin were the most frequently prescribed antibiotics in hospitals with culture facilities, while a third-generation cephalosporin was mostly administered in hospital without culture facilities. The median durations of antibiotic therapy were 19 and 9 days in culture-proven and culture-negative EOS groups, respectively.

CONCLUSIONS

The overall incidence of EOS and culture-proven EOS was high in Indonesia, with diverse and prolonged use of antibiotics. Prospective antibiotic surveillance and stewardship interventions are required.

Initial respiratory support modality and outcome in preterm infants with less than 32 weeks of gestation in China: A multicentre retrospective cohort study

BACKGROUND

For initial respiratory management, continuous positive airway pressure (CPAP) is increasingly used for preterm infants, especially for gestational age less than 32 weeks. However, neonatologists are concerned about the potential risks of CPAP support failure.

OBJECTIVES

To examine the association between different initial respiratory support modalities and the outcomes of preterm infants at <32 weeks of gestation across multiple neonatal intensive care units (NICU) in China.

METHODS

This study was carried out over a period of 12 months in 2018. Unadjusted relative risks (RR) for demographic and clinical characteristics were calculated for CPAP failure and CPAP success in the total cohort using log-linear model based on generalised estimating equations for clustered observations.

RESULTS

Among 1560 preterm infants delivered at <32 weeks, the incidence of CPAP failure was 10.3%. After adjustment for demographic and clinical factors, the relative risk of mortality (RR 7.54, 95% CI 5.56, 10.44), pneumothorax (RR 9.85, 95% CI 2.89, 61.53), pulmonary haemorrhage (RR 7.78, 95% CI 4.51, 14.64) and BPD (RR 3.65, 95% CI 3.65, 4.51) were considerably higher for infants in the CPAP failure group than those in the CPAP-S group. However, the risk of poor outcomes in CPAP failure infants was similar to that of those in the initial mechanical ventilation (MV) group.

CONCLUSIONS

Continuous positive airway pressure failure was associated with an increased risk of mortality and major morbidities, including BPD, pulmonary haemorrhage and pneumothorax, and was comparable to the risk associated with initial MV.

Centers for disease control and prevention guidelines identified more neonates at risk of early-onset sepsis than the Kaiser-Permanente calculator

AIM

Our aim was to retrospectively compare how many cases of early-onset sepsis (EOS) would have been predicted by the the Kaiser-Permanente (KP) calculator and the United States Centers for Disease Control and Prevention (CDC) guidelines.

METHODS

This observational retrospective cohort study comprised 50 newborn infants with documented EOS who were born at the Kaplan Medical Centre, Israel, between 2001 and 2018. We retrospectively evaluated whether the KP calculator and the CDC recommendations would have recommended antibiotic treatment if they had been implemented within four hours of birth.

RESULTS

EOS was diagnosed in 50 of the 109 877 infants born from 34 weeks of gestation. By four hours of birth, 18 were symptomatic, five had an equivocal clinical status, and 27 were asymptomatic. The KP calculator would have recommended antibiotic treatment for 19 (38%) neonates: 18 who were symptomatic and one who was initially asymptomatic. The CDC guidelines would have recommended antibiotic treatment for 27 (54%) nenonates: those 19 plus all 5 with equivocal status and other 3 who were asymptomatic.

CONCLUSION

Using the CDC guidelines would have identified more equivocal and asymptomatic EOS cases within four hours of birth than the KP calculator. Enhanced observation is recommended when using the KP calculator.

[Sepsis risk calculator-guided antibiotic management in neonates with suspected early-onset sepsis]

OBJECTIVE

To evaluate the efficacy of sepsis risk calculator (SRC) in guiding antibiotic use in neonates with suspected early-onset sepsis (EOS).

METHODS

A total of 284 neonates with a gestational age of ≥ 35 weeks were enrolled as the control group, who were hospitalized in the Children's Hospital of Chongqing Medical University from March to July, 2019 and were suspected of EOS. Their clinical data were retrospectively collected and the use of antibiotics was analyzed based on SRC. A total of 170 neonates with a gestational age of ≥ 35 weeks were enrolled as the study group, who were admitted to the hospital from July to November, 2020 and were suspected of EOS. SRC was used prospectively for risk scoring to assist the decision making of clinical antibiotic management. The two groups were compared in terms of the rate of use of antibiotics, blood culture test rate, clinical outcome, and adherence to the use of SRC.

RESULTS

Compared with the control group, the study group had a significantly higher SRC score at birth and on admission (P < 0.05). The rate of use of antibiotics in the study group was significantly lower than that in the control group[84.7% (144/170) vs 91.5% (260/284), 6.8% decrease; P < 0.05]. The blood culture test rate in the study group was also significantly lower than that in the control group (85.3% vs 91.9%, P < 0.05). There was no significant difference between the two groups in the incidence rate of adverse outcomes and the final diagnosis of EOS (P > 0.05).

CONCLUSIONS

The use of SRC reduces the rate of empirical use of antibiotics in neonates with suspected EOS and does not increase the risk of adverse outcomes, and therefore, it holds promise for clinical application.

A comparison between risk-factor guidance for neonatal early-onset sepsis and Kaiser Permanente sepsis risk calculator in a Greek cohort

BACKGROUND

The management of neonates with early-onset sepsis (EOS) is based on maternal risk factors and infant clinical indications. An online sepsis risk calculator (SRC) has been established taking into consideration how clinical appearance modifies the initial risk for EOS.

AIMS

To compare our clinical practice based on risk-factor guidance with that projected through the application of the SRC.

STUDY DESIGN

Retrospective cohort study.

METHODS

All neonates ≥34 weeks' gestation, during 01/2019-8/2020. The SRC was applied retrospectively to determine the recommendation. EOS was defined based on a positive blood or cerebrospinal fluid culture-proven infection within 72 h of age. Clinical sepsis was defined according to the European Medicine Agency criteria.

OUTCOME MEASURES

Differences on antibiotic administration and management.

RESULTS

Overall, 2084 infants were identified, of whom 150 (7%) received antibiotics. Of them, 34 infants were diagnosed with clinical sepsis, while one was diagnosed with culture positive-proven EOS. Applying SRC, 87 (4%) infants would have received antibiotics. Clinical sepsis was diagnosed in 29 infants, while one infant had culture positive-proven EOS. Sixty-seven of 150 (45%) infants that received antibiotics would not have been treated based on SRC; five infants that developed clinical sepsis would have been missed with SRC. A 99.7% agreement between both guidance was found regarding infants not indicated for antibiotics. SRC application led to an absolute reduction of antibiotic administration by 2.93% (95% CI 2.19-3.75), p < 0.0001.

CONCLUSIONS

The adoption of SRC would have significantly reduced antibiotic usage; however, a significant portion of cases with clinical EOS would have been missed.

C-reactive protein in infants with no evidence of early-onset sepsis

OBJECTIVE

C-reactive protein (CRP) is one of the most extensively used biomarkers in the investigation of early-onset sepsis (EOS). Current evidence suggests the normal kinetics of serum CRP should be considered when evaluating infants for presumable EOS. The current study aimed to evaluate the CRP kinetics, and to establish percentiles in a cohort of term and near-term infants with no evidence of confirmed or clinical EOS.

METHODS

We retrospectively reviewed the medical records of all neonates ≥34 weeks' gestation screened for presumable EOS, from January until December 2019. We also recorded the clinical management, the blood culture, serial CRP, and white blood cell count analysis of each infant. All infants that received antibiotics for confirmed or presumed EOS were excluded from the analysis.

RESULTS

During the study period, 145 infants were detected; 109 (75%) term and 36 (25%) preterm. Term infants had significantly higher median values of CRP at all time points in comparison to preterm infants. Term infants presented a significant rise of CRP at 24 and 36 h, with a peak at 24 h (median 4 (range 1-12) mg/L). Preterm infants had a significant rise of CRP at 24 but not at 36 h, with a peak at 24 h (median 3 (range 1-9) mg/L). In term infants, the 90th percentile of CRP at 24 h was 10.80 mg/L and the 97th percentile was 12.00 mg/L. In preterm infants, the 90th percentile of CRP at 24 h was 7.60 mg/L and the 97th percentile was 8.00 mg/L.

CONCLUSIONS

Term and near-term asymptomatic infants had a rise in CRP during the first days of life. Term infants had a more pronounced CRP response in comparison to preterm infants.

Laboratory-confirmed bloodstream infections in two large neonatal units in sub-Saharan Africa

BACKGROUND

Epidemiological data on neonatal bloodstream infections (BSI) in sub-Saharan Africa are extremely limited.

METHODS

A comparative analysis of laboratory-confirmed neonatal BSI episodes was conducted retrospectively in two large neonatal units in Botswana and South Africa (January 1 to December 31, 2017). Routine laboratory and ward register data were used to determine BSI rates, the pathogen spectrum, and BSI outcomes.

RESULTS

In 2017, the Princess Marina Hospital (PMH) and Tygerberg Hospital (TBH) neonatal units admitted 1187 and 2826 neonates, respectively. The BSI incidence rate was 12.1/1000 patient-days (95% confidence interval (CI) 10.2-14.3) at PMH and 3.5/1000 patient-days (95% CI 2.9-4.1) at TBH (p < 0.0001). Most BSI episodes were hospital-acquired (260/284; 91.6%). The blood culture contamination rate was substantially higher at PMH than TBH (152/1116 (13.6%) vs 122/2559 (4.8%); p < 0.001). The crude mortality rate in neonates with BSI was 21.2% (53/250) and significantly higher at TBH than PMH (38/128 (29.7%) vs 15/122 (12.3%), p = 0.001). Factors independently associated with death were birth weight <1500 g (adjusted odds ratio (aOR) 2.8, 95% CI 1.3-6.4; p = 0.02) and male sex (aOR 2.1, 95% CI 1.1-3.7; p = 0.01). Klebsiella pneumoniae was the dominant BSI pathogen in both units, accounting for two-thirds of BSI, and was associated with a large infection outbreak at PMH. Antibiotic resistance rates were substantial in both neonatal units, particularly for K. pneumoniae (98/122 (80.3%), extended-spectrum beta-lactamase (ESBL)-producers) and Staphylococcus aureus (22/33 (66.7%), methicillin-resistant).

CONCLUSIONS

BSI rates and associated mortality were substantial in these two neonatal units in sub-Saharan Africa. ESBL-producing K. pneumoniae remains a leading BSI and outbreak pathogen.

C-reactive protein as a predictor of meningitis in early onset neonatal sepsis: a single unit experience

Objectives To determine whether there is a cut off value of serum C-reactive protein (CRP) associated with a higher risk of meningitis in suspected early onset sepsis (EOS) (onset birth to 7 days of life). Methods A retrospective cohort study on neonates admitted in neonatal intensive care unit at McMaster Children's Hospital from January 2010 to 2017 and had lumbar puncture (LP) and CRP for workup of EOS. Included subjects had either (a) non-traumatic LP or (b) traumatic LP with cerebral spinal fluid (CSF) polymerase chain reaction or gram stain or culture-positive or had received antimicrobials for 21 days. Excluded were CSF done for metabolic errors, before cytomegalovirus (CMV) treatment; from ventriculo-peritoneal (VP) shunts; missing data and contamination. Neonates were classified into definite and probable meningitis and on the range of CRP. We calculated sensitivity, specificity, and likelihood ratios for CRP values; and area under the receiver operating characteristic (AUROC) curve. Results Out of 609 CSF samples, 184 were eligible (28 cases of definite or probable meningitis and 156 controls). Sensitivity, specificity, predictive values, likelihood ratios, and AUROC were too low to be of clinical significance to predict meningitis in EOS. Conclusions Serum CRP values have poor discriminatory power to distinguish between subjects with and without meningitis, in symptomatic EOS.

Active antibiotic discontinuation in suspected but not confirmed early-onset neonatal sepsis-A quality improvement initiative

AIM

To study whether a simple targeted intervention could reduce unwarranted antibiotic treatment in near-term and term neonates with suspected, but not confirmed early-onset sepsis.

METHODS

A quality improvement initiative in three Norwegian neonatal intensive care units. The intervention included an inter-hospital clinical practice guideline for discontinuing antibiotics after 36-48 hours if sepsis was no longer suspected and blood cultures were negative in neonates ≥ 34+0 weeks of gestation. Two units used procalcitonin in decision-making. We compared data 12-14 months before and after guideline implementation. The results are presented as median with interquartile ranges.

RESULTS

A total of 284 infants (2.5% of all births ≥ 34+0 weeks of gestation) received antibiotics before and 195 (1.8%) after guideline implementation (P = .0018). The two units that used procalcitonin discontinued antibiotics earlier after guideline implementation than the unit without procalcitonin. Neonates not diagnosed with sepsis were treated 49 (31-84) hours before and 48 (36-72) hours after guideline implementation (P = .68). In all infants, including those diagnosed with sepsis, antibiotic treatment duration was reduced from 108 (60-144) to 96 (48-120) hours (P = .013).

CONCLUSION

Antibiotic treatment duration for suspected, but not confirmed early-onset sepsis did not change. However, treatment duration for all infants and the proportion of infants commenced on antibiotics were reduced.

Reduced Antibiotic Exposure by Serial Physical Examinations in Term Neonates at Risk of Early-onset Sepsis

BACKGROUND

Suspected early-onset sepsis (EOS) results in antibiotic treatment of a substantial number of neonates who are uninfected. We evaluated if an approach using serial physical examinations (SPEs) can reduce antibiotic exposure for suspected EOS in term neonates during the first 3 days of life, without affecting safety.

METHODS

Within a quality-improvement framework, SPEs for 24-48 hours for neonates with suspected EOS was implemented in the neonatal intensive care unit, Stavanger, Norway. The proportion of neonates ≥37 weeks gestation exposed to antibiotics, antibiotic therapy-days and the safety outcome time from birth to start antibiotics were compared between a baseline period (April 2014-February 2016), when a risk factor based approach was used, and a post-SPE-implementation period (January 2017-November 2018).

RESULTS

We included all term live born neonates (n = 17,242) in the 2 periods. There was a 57% relative reduction in neonates exposed to antibiotics; 2.9% in the baseline and 1.3% in the post-implementation period, P < 0.001. There was a 60% relative reduction in mean antibiotic therapy-days/1000 patient-days; from 320 to 129, P < 0.001, and a 50% relative reduction in time to initiate antibiotics in suspected EOS-cases, from median (interquartile range) 14 (5-28) to 7 (3-17) hours, P = 0.003. The incidence of culture-positive EOS remained unchanged. There were no infection-attributable deaths.

CONCLUSIONS

Implementing SPE to guide empiric antibiotic therapy in term neonates with suspected EOS more than halved the burden of antibiotic exposure, without delay of antibiotic treatment of infected neonates or increased sepsis-related mortality.

Efficacy and safety of applying a neonatal early-onset sepsis risk calculator in China

AIM

To evaluate and compare the performance of the early-onset sepsis (EOS) risk calculator with procalcitonin (PCT), complete blood count (CBC) and C-reactive protein (CRP) for predicting neonatal EOS.

METHODS

This was a retrospective case-control study of neonates who were ≥34 weeks of gestation and ≤12 h of age at admission to our hospital between January 2017 and December 2018. Neonates with strictly defined EOS and those without evidence of infection were included in this study. We reviewed and collected the laboratory data and medical charts of the included neonates. The EOS risk scores for all neonates were calculated using the EOS risk calculator, and the results were analysed and compared with blood biomarkers.

RESULTS

A total of 501 neonates, including 353 infected and 148 uninfected infants, met the inclusion criteria for the study. Comparing these predictors, PCT had the best predictive value (sensitivity: 87.5%, specificity: 95.5%), closely followed by the EOS risk calculator (sensitivity: 81.16%, specificity: 93.92%). Multivariate logistic regression found that risk scores calculated by the EOS risk calculator had strong associations with EOS as an independent risk factor (odds ratio: 57.37, P < 0.05). The combination of the EOS risk calculator, PCT, CBC and CRP could increase the predictive value of the model and reach an area under the receiver operating characteristic curve of 0.987 for predicting EOS.

CONCLUSIONS

In this pilot study, applying the EOS calculator in China, the EOS risk calculator and PCT showed good predictive value compared to CBC and CRP. Risk scores from the EOS risk calculator strongly correlated with EOS, and the EOS risk calculator offered increased predictive value when used in combination with blood biomarkers.

The evaluation of the appropriate gentamicin use for preterm infants

Gentamicin (GM) is used for neonates as the initial treatment for neonatal bacterial infection. An association between high trough GM levels and the elevation of the serum creatinine (sCr) level and hearing loss has been reported, although there have been no reports investigating the serial changes in the sCr level in preterm neonates treated with GM. The present study evaluated the serial changes in the sCr level and the incidence of hearing loss in preterm neonates treated with GM. This study included 56 neonates born at a gestational age of 32-36 weeks. Fifteen (group 1) and 20 (group 2) neonates were treated with 2.5 mg/kg of GM every 12 h and 4 mg/kg of GM every 36 h, respectively. Group 3 included 21 neonates without GM therapy. Serum GM levels, serial changes in the sCr levels, and the incidence of hearing loss were then compared among the three groups. The serum trough GM level in group 2 was significantly lower than that in group 1 (P < 0.001), whereas the serum peak GM levels in these groups were almost the same. The ratio of the sCr level at birth to that at the 5th day of life in group 1 was the lowest among the 3 groups. No neonates had hearing loss. GM therapy worsened the sCr level in late preterm neonates, especially those with multiple doses per day. The appropriate use of GM is needed in order to prevent the occurrence of nephrotoxicity.

Management of febrile infants aged 1 month and less than 3 months in a French university hospital: Clinical practice evaluation

BACKGROUND

Management of febrile infants is challenging due to the increased risk of serious bacterial infections and it varies among physicians and hospitals. The goals of this study were to describe and compare the management of febrile infants aged 1-2 months in a hospital in 2011 and 2016.

METHODS

We conducted a retrospective study in the Bordeaux Pellegrin University Hospital, France, in 2011 and 2016. All infants aged 1-2 months with diagnosis codes referring to fever were included. Data on infant characteristics, fever episodes, clinical symptoms, and management were collected from medical charts. Univariate analyses and multivariate logistic models were used.

RESULTS

A total of 530 infants were included; 89.2% had blood testing and 81.1% urine testing; 79.6% of the infants were hospitalized, three of them in the pediatric intensive care unit. The median hospitalization duration was 3 days. In the sample investigated, 59.8% of the infants received antibiotic therapy and 128 (24.1%) had bacterial infections with no difference between 2011 and 2016. The main bacterial infection was pyelonephritis (86.7%). Urethral catheterization was implemented in 2016, whereas a urine bag was utilized for 174 out of 177 infants in 2011. The percentage of contaminated urine cultures was higher in 2011 (35.9%) than in 2016 (19.6%, P<0.001). The hospitalization rate was higher in 2016.

CONCLUSIONS

Management of febrile infants changed between 2011 and 2016. The hospitalization rate and antibiotic therapy use remained high regarding the rate of bacterial infection. Use of urethral catheterization decreased the level of contamination.

Are antibiotics a risk factor for the development of necrotizing enterocolitis-case-control retrospective study

Previous studies have identified numerous risk factors associated with necrotizing enterocolitis (NEC) in very low birth weight (VLBW; birth weight less than 1500 g) infants. One of the potential pathophysiological contributors could be antibiotic therapy. Our aim was to explore the association between antibiotic exposure and NEC in VLBW infants. We designed a retrospective 1:2 case-control cohort study in a level III neonatal intensive care unit. Our study group composed of VLBW infants born between January 2012 and December 2014 with a diagnosis of NEC stage IIA or greater (Bell's modified criteria). Our intent was to match every case in the study group to two controls. Our primary outcome was an association between antibiotic exposure and NEC. Twenty-two cases of NEC were matched to 32 controls. The infants who developed NEC were exposed to a statistically significantly more frequent number of antibiotic courses and to more days on any antibiotic prior to the development of NEC. There were significant differences between cases and controls with respect to the duration of exposure to gentamicin and meropenem specifically.Conclusion: The data from our study demonstrate that prolonged exposure to antibiotic therapy is associated with an increased risk of NEC among VLBW infants. Furthermore, gentamicin and meropenem, but not other antibiotics, had a significant association with the incidence of NEC. What is known: • Early antibiotic exposure is a risk factor for the development of necrotising enterocolitis (NEC) in very low birth weight infants • Prolonged initial empirical antibiotic course for ≥ 5 days, despite sterile blood culture, is associated with an increased risk of developing NEC What is new: • The cumulative total number of days of antibiotic exposure is associated with an increased risk of developing NEC • Gentamicin and meropenem, but not other antibiotics, had a significant association with the incidence of NEC in our study.

Biomarkers for Infection in Children: Current Clinical Practice and Future Perspectives

Biomarkers have become an integral part of the clinical decision-making process of clinicians dealing with febrile children. C-reactive protein, procalcitonin and white blood cell count are probably the most studied ones. Crucial to using biomarkers is the understanding of how a test result will alter post-test probabilities and then impact on clinical decision making. Improved analytical and computational platforms have enabled the next generation of advanced biomarker discovery studies. Promising combinations of candidate biomarkers for a diverse spectrum of febrile illnesses, such as viral and bacterial infections, have been identified using proteomics, RNA gene expression and metabolomics.

[Predictive value of umbilical arterial cord pH on complications during hospitalization in neonates after cesarean section]

OBJECTIVE

To analyze the predictive value of umbilical arterial cord pH on complications of hospitalized neonates after cesarean section.

METHODS

This was a retrospective cohort study and carried out in Peking University First Hospital from January 1, 2017 to June 30, 2017. Neonates who were delivered by cesarean section were enrolled. The primary endpoint was the incidence of complications during in-hospital stay (including infection, aspiration pneumonia, myocardial damage, etc.). The subjects were divided into two groups:with or without complication. The umbilical arterial cord pH values were compared between the two groups. Perinatal baseline characteristics of maternal and neonatal data were recorded. The ROC curve was used to analyze the value of umbilical arterial cord pH in predicting neonatal complications during hospitalization. Multivariate Logistic regression was employed to analyze the potential risk factors of neonatal complications.

RESULTS

In the study, 872 neonates were included in the final analysis (541 in elective surgery and 331 in emergency surgery). The overall incidence of neonatal complications during hospitalization was 14.1%. The first three higher incidences were infection, aspiration pneumonia and myocardial damage. The average pH value in neonates without complication was 7.31 while 7.29 in neonates with complication. There was statistical significance between the two groups (P<0.001). The overall incidence of pH≤7.20 was 3.1% (27/872). The patients in neonates without complication had higher incidence of pH≤7.20 than those in neonates with complication (1.6% vs. 12.2%, P<0.001). Multivariate Logistic regression showed 6 risk factors of neonatal hospitalized complications including preterm delivery (OR=8.224, 95%CI: 4.910-13.777, P<0.001), pregnancy-induced hypertension (OR=1.886, 95%CI: 1.004-3.546, P=0.049), intrauterine growth restriction (OR=4.429, 95%CI: 1.280-15.330, P=0.019), emergency cesarean section (OR=2.711, 95%CI: 1.682-4.369, P<0.001), umbilical arterial blood gas pH≤7.20 (OR=7.420, 95%CI: 2.951-18.655, P<0.001) and 5-minute Apgar score <10 scores (OR=11.849, 95%CI: 3.977-35.128, P<0.001). The areas under the ROC curve of umbilical arterial blood gas pH in all neonatal, elective and emergency cesarean section were 0.570 (95%CI: 0.508-0.633, P=0.012), 0.559 (95%CI: 0.465-0.652, P=0.189) and 0.617 (95%CI: 0.538-0.697, P=0.002), respectively.

CONCLUSION

Umbilical arterial cord pH≤7.20 was related with increased incidence of neonatal complications after cesarean section,but ROC curve analysis showed a lower predictive value.

[Research advances in rational use of antibiotics in neonates]

Antibiotics are commonly used in the neonatal intensive care unit (NICU), but unnecessary or long-time exposure to antibiotics early after birth can increase the risk of poor prognosis of neonates. Antibiotic treatment in the NICU often begins with empiric therapy, but no uniform standards have been established for the initiation and course of empiric therapy. In neonates with negative bacterial culture results and stable clinical manifestations, empiric antibiotic therapy should be terminated in a timely manner. There are significant differences in the use of antibiotics in different NICUs. A targeted antimicrobial stewardship program is an effective way for optimizing the use of antibiotics in the NICU.

C-reactive protein and immature-to-total neutrophil ratio have no utility in guiding lumbar puncture in suspected neonatal sepsis

AIM

Meningitis may complicate neonatal sepsis, but there is scant evidence to inform the decision to perform a lumbar puncture (LP) and considerable variation in practice. We investigated whether inflammatory markers - C-reactive protein (CRP) and immature-to-total neutrophil ratio (ITR) - were predictive of meningitis or significant cerebrospinal fluid (CSF) pleocytosis and useful in guiding the decision to perform a LP.

METHODS

We studied all inpatients in a single tertiary neonatal unit who were <6 months of age who had a LP performed between March 2011 and October 2014. We categorised CSF results as follows: (i) culture-positive meningitis; (ii) probable culture-negative meningitis but meeting a priori criteria for significant CSF leucocytosis; or (iii) no evidence of meningitis. CRP and ITR obtained within 48 h of LP were analysed. We assessed the test performance of CRP and ITR by area under receiver operating characteristic curves.

RESULTS

A total of 757 (male 471, 62.2%) infants were included. The median (interquartile range) gestational age was 38.4 weeks (30-40.3), and birthweight was 2940 g (1330-3560). Ten (1.3%) infants had culture-positive meningitis; 71 (9.4%) were classified as probable culture-negative meningitis and 676 (89.3%) as non-meningitis. The area under receiver operating characteristic curve for culture-positive and probable culture-negative meningitis was 0.43 for CRP (95% confidence interval 0.36-0.51) and 0.58 for ITR (0.51-0.65). At a CRP threshold of 30 mg/L, there was a positive likelihood ratio (LR) of 0.77 and a negative LR of 1.44.

CONCLUSIONS

CRP and ITR perform poorly in identifying infants with confirmed or probable meningitis. The decision to perform an LP should be more focused on clinical grounds and/or a positive blood culture and less on inflammatory or haematological markers in isolation.

Reviewing the WHO guidelines for antibiotic use for sepsis in neonates and children

Background Guidelines from 2005 for treating suspected sepsis in low- and middle-income countries (LMIC) recommended hospitalisation and prophylactic intramuscular (IM) or intravenous (IV) ampicillin and gentamicin. In 2015, recommendations when referral to hospital is not possible suggest the administration of IM gentamicin and oral amoxicillin. In an era of increasing antimicrobial resistance, an updated review of the appropriate empirical therapy for treating sepsis (taking into account susceptibility patterns, cost and risk of adverse events) in neonates and children is necessary. Methods Systematic literature review and international guidelines were used to identify published evidence regarding the treatment of (suspected) sepsis. Results Five adequately designed and powered studies comparing antibiotic treatments in a low-risk community in neonates and young infants in LMIC were identified. These addressed potential simplifications of the current WHO treatment of reference, for infants for whom admission to inpatient care was not possible. Research is lacking regarding the treatment of suspected sepsis in neonates and children with hospital-acquired sepsis, despite rising antimicrobial resistance rates worldwide. Conclusions Current WHO guidelines supporting the use of gentamicin and penicillin for hospital-based patients or gentamicin (IM) and amoxicillin (oral) when referral to a hospital is not possible are in accordance with currently available evidence and other international guidelines, and there is no strong evidence to change this. The benefit of a cephalosporin alone or in combination as a second-line therapy in regions with known high rates of non-susceptibility is not well established. Further research into hospital-acquired sepsis in neonates and children is required.

Infant Group B Streptococcal Disease Incidence and Serotypes Worldwide: Systematic Review and Meta-analyses

Background

Group B Streptococcus (GBS) remains a leading cause of neonatal sepsis in high-income contexts, despite declines due to intrapartum antibiotic prophylaxis (IAP). Recent evidence suggests higher incidence in Africa, where IAP is rare. We investigated the global incidence of infant invasive GBS disease and the associated serotypes, updating previous estimates.

Methods

We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data regarding invasive GBS disease in infants aged 0–89 days. We conducted random-effects meta-analyses of incidence, case fatality risk (CFR), and serotype prevalence.

Results

We identified 135 studies with data on incidence (n = 90), CFR (n = 64), or serotype (n = 45). The pooled incidence of invasive GBS disease in infants was 0.49 per 1000 live births (95% confidence interval [CI], .43–.56), and was highest in Africa (1.12) and lowest in Asia (0.30). Early-onset disease incidence was 0.41 (95% CI, .36–.47); late-onset disease incidence was 0.26 (95% CI, .21–.30). CFR was 8.4% (95% CI, 6.6%–10.2%). Serotype III (61.5%) dominated, with 97% of cases caused by serotypes Ia, Ib, II, III, and V.

Conclusions

The incidence of infant GBS disease remains high in some regions, particularly Africa. We likely underestimated incidence in some contexts, due to limitations in case ascertainment and specimen collection and processing. Burden in Asia requires further investigation.

High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial

OBJECTIVE

To compare the time taken by preterm infants with evolving chronic lung disease to achieve full oral feeding when supported with humidified high flow nasal cannula (HFNC) or nasal continuous positive airway pressure (NCPAP).

DESIGN

Single centre randomised controlled trial.

SETTING

Level III neonatal intensive care unit at the Coombe Women and Infants University Hospital, Dublin, Ireland.

PATIENTS

Very low birthweight (birth weight <1500 g) infants born before 30 weeks' gestation who were NCPAP-dependent at 32 weeks corrected gestational age were eligible to participate.

INTERVENTIONS

Enrolled infants were randomised in a 1:1 ratio to receive HFNC or NCPAP. Participants were monitored daily until full oral feeding was established and the baby was off respiratory support.

MAIN OUTCOME MEASURES

Our primary outcome was the number of days taken to establish full oral feeds (defined as oral intake ≥120 mL/kg/day) from the time of randomisation. We estimated that enrolling 44 subjects (22 in each group) would allow us demonstrate a 7-day difference in our primary outcome with 80% power and α of 5%.

RESULTS

Forty-four infants were randomised (22 to HFNC vs 22 to NCPAP). The mean time to achieve full oral feeding was not different between the groups (HFNC 36.5 (±18.2) days vs NCPAP 34.1 (±11.2) days, p=0.61).

CONCLUSIONS

Preterm infants treated with HFNC did not achieve full oral feeding more quickly than infants treated with NCPAP.

TRIAL REGISTRATION NUMBER

ISRCTN66716753.

[Clinical observation of newborns with infection risk: A safe practice]

INTRODUCTION

Early-onset neonatal sepsis refers to an infection which starts during the first 72hours of birth, and can lead to significant morbidity and mortality. Scientific evidence shows that infected infants present with symptoms during the first hours after delivery. There has been a significant decrease in this condition with the implementation of guidelines for its prevention. However, International guidelines still recommend the evaluation of these infants using painful tests.

MATERIAL AND METHODS

A prospective cohort study was conducted on all asymptomatic infants born at>35 weeks gestation with one or more risk factors in a single tertiary care centre from 2011 to 2015. They were periodically observed in newborn nursery from admission until discharge looking for signs of infection.

RESULTS

Out of the 9,424 babies born during this period, 1425 were included in the study. A total of 53 infants were admitted to the neonatal unit, half of them because of sepsis suspicion. Finally, just 7 were discharged with the diagnosis of sepsis. All these 7 presented with symptoms during their first 72hours of life. No sepsis was reported in asymptomatic infants.

CONCLUSIONS

Truly infected infants present with symptoms during their first hours of life. This study supports the observation of infants at risk as a safe practice to detect early-onset sepsis.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

BACKGROUND

Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis.

OBJECTIVES

To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit.

DESIGN

Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention).

SETTING

Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London.

PARTICIPANTS

Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital.

METHODS

Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth.

MAIN OUTCOME

Incidence of early-onset GBS infections.

RESULTS

6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05).

CONCLUSIONS

Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

Presepsin for the detection of early-onset sepsis in preterm newborns

BACKGROUND

Early-onset sepsis (EOS) is responsible for an important fraction of neonatal morbidity and mortality all over the world. The aim of this study was to assess whether presepsin (P-SEP) can be a more accurate biomarker of EOS compared with pro-calcitonin (PCT) and C-reactive protein (CRP).

STUDY DESIGN

Consecutive preterm neonates (<34 wk gestational age, admitted to Neonatal Intensive Care Unit by 6 h of age and undergoing sepsis evaluation) were recruited as part of a case-matched control study. We determined CRP, PCT and P-SEP at admission, and then at 12, 24, and 48 h of age. Neonates recruited into the study were divided into the EOS group (n = 32) and the uninfected group (n =38) according to their infection screening.

RESULTS

P-SEP values were significantly higher in the EOS group than in the uninfected group at different time intervals. The highest accuracy was achieved by P-SEP at 24 h after birth. The AUC for P-SEP was 0.97. In our sample, P-SEP achieved the best accuracy for prediction of EOS at the cut-off of 788 ng/l with 93% sensitivity and 100% specificity.

CONCLUSIONS

This study shows that P-SEP is significantly higher in preterm infants with EOS compared with uninfected infants.

Flow cytometric white blood differential using CytoDiff™ in the diagnosis of neonatal early-onset infection

OBJECTIVE

Neonatal early-onset infection is a life-threatening disease, requiring early diagnosis and treatment. Newborns at risk are identified by a combination of risk factors, clinical signs of infection and laboratory parameters such as white blood cell count and C-reactive protein (CRP). This method is labor-intensive, time consuming and has a variable reproducibility. New reliable diagnostic markers are needed to identify neonatal infection. This study presents additional leukocyte differential parameters produced by the automated flow cytometry and processing software using CytoDiff™ reagent (Beckman Coulter) in newborns suspected for early-onset infection.

METHODS

An analytic prospective observational case-control study was performed in which 185 newborns were included and retrospectively allocated into two groups, "infection likely" and "infection unlikely". Leukocyte parameters of the CytoDiff™ technique were compared with microscopic slide differentiation and routine tests.

RESULTS

We showed significant lower numbers of monocytes, CD16(-) monocytes and lymphocytes (including T+/NK-lymphocytes) in neonates suspected for early-onset infection using CytoDiff™ technique. The manual counting did not demonstrate changes with respect to the number of monocytes in these neonates.

CONCLUSIONS

The automated routine CytoDiff™ leukocyte differential provides an interesting additional diagnostic tool, next to routine laboratory diagnostics, in the diagnosis of neonatal early-onset infection.

Antibiotic Prescriptions and Prophylaxis in Italian Children. Is It Time to Change? Data from the ARPEC Project

BACKGROUND

Antimicrobials are the most commonly prescribed drugs. Many studies have evaluated antibiotic prescriptions in the paediatric outpatient but few studies describing the real antibiotic consumption in Italian children's hospitals have been published. Point-prevalence survey (PPS) has been shown to be a simple, feasible and reliable standardized method for antimicrobials surveillance in children and neonates admitted to the hospital. In this paper, we presented data from a PPS on antimicrobial prescriptions carried out in 7 large Italian paediatric institutions.

METHODS

A 1-day PPS on antibiotic use in hospitalized neonates and children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven institutions in seven Italian cities were involved. The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey, who had at least one on-going antibiotic prescription. For all patients data about age, weight, underlying disease, antimicrobial agent, dose and indication for treatment were collected.

RESULTS

The PPS was performed in 61 wards within 7 Italian institutions. A total of 899 patients were eligible and 349 (38.9%) had an on-going prescription for one or more antibiotics, with variable rates among the hospitals (25.7% - 53.8%). We describe antibiotic prescriptions separately in neonates (<30 days old) and children (> = 30 days to <18 years old). In the neonatal cohort, 62.8% received antibiotics for prophylaxis and only 37.2% on those on antibiotics were treated for infection. Penicillins and aminoglycosides were the most prescribed antibiotic classes. In the paediatric cohort, 64.4% of patients were receiving antibiotics for treatment of infections and 35.5% for prophylaxis. Third generation cephalosporins and penicillin plus inhibitors were the top two antibiotic classes. The main reason for prescribing antibiotic therapy in children was lower respiratory tract infections (LRTI), followed by febrile neutropenia/fever in oncologic patients, while, in neonates, sepsis was the most common indication for treatment. Focusing on prescriptions for LRTI, 43.3% of patients were treated with 3rd generation cephalosporins, followed by macrolides (26.9%), quinolones (16.4%) and carbapenems (14.9%) and 50.1% of LRTI cases were receiving more than one antibiotic. For neutropenic fever/fever in oncologic patients, the preferred antibiotics were penicillins with inhibitors (47.8%), followed by carbapenems (34.8%), aminoglycosides (26.1%) and glycopeptides (26.1%). Overall, the 60.9% of patients were treated with a combination therapy.

CONCLUSIONS

Our study provides insight on the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children. An over-use of third generation cephalosporins both for prophylaxis and treatment was the most worrisome finding. A misuse and abuse of carbapenems and quinolones was also noted. Antibiotic stewardship programs should immediately identify feasible targets to monitor and modify the prescription patterns in children's hospital, also considering the continuous and alarming emergence of MDR bacteria.