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Wawrzoniak T, Romańska J. Effect of Serial Clinical Observation Complemented by Point-of-Care Blood Culture Volume Verification on Antibiotic Exposure in Newborns. Glob Pediatr Health 2024; 11:2333794X231226057. [PMID: 38269318 PMCID: PMC10807344 DOI: 10.1177/2333794x231226057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024] Open
Abstract
Objective. This study evaluated the effects of serial clinical observation strategy complemented by point-of-care verification of blood culture volume in managing term and near-term newborns at risk for early-onset sepsis. Methods. We used a "before-and-after" approach. Infants born at ≥35 0/7 weeks' gestation were eligible. Our strategy was based on serial clinical observation complemented with point-of-care verification of blood culture volume. Two separate 12-month periods were analyzed. The number of infants exposed to antibiotics started during the first 3 days of life was compared before and after introducing the strategy. Results. During the post-intervention period, 0.6% of infants received antibiotic therapy, compared to 4.1% during the pre-intervention period (P < .001; relative risk [RR]: 0.15; 95% CI: 0.08-0.28). Conclusion. Serial clinical observation complemented with verification of blood culture volume might reduce antibiotic utilization in newborns in the early postnatal period.
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Guan G, Joshi NS, Frymoyer A, Achepohl GD, Dang R, Taylor NK, Salomon JA, Goldhaber-Fiebert JD, Owens DK. Resource Utilization and Costs Associated with Approaches to Identify Infants with Early-Onset Sepsis. MDM Policy Pract 2024; 9:23814683231226129. [PMID: 38293656 PMCID: PMC10826394 DOI: 10.1177/23814683231226129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Objective. To compare resource utilization and costs associated with 3 alternative screening approaches to identify early-onset sepsis (EOS) in infants born at ≥35 wk of gestational age, as recommended by the American Academy of Pediatrics (AAP) in 2018. Study Design. Decision tree-based cost analysis of the 3 AAP-recommended approaches: 1) categorical risk assessment (categorization by chorioamnionitis exposure status), 2) neonatal sepsis calculator (a multivariate prediction model based on perinatal risk factors), and 3) enhanced clinical observation (assessment based on serial clinical examinations). We evaluated resource utilization and direct costs (2022 US dollars) to the health system. Results. Categorical risk assessment led to the greatest neonatal intensive care unit usage (210 d per 1,000 live births) and antibiotic exposure (6.8%) compared with the neonatal sepsis calculator (112 d per 1,000 live births and 3.6%) and enhanced clinical observation (99 d per 1,000 live births and 3.1%). While the per-live birth hospital costs of the 3 approaches were similar-categorical risk assessment cost $1,360, the neonatal sepsis calculator cost $1,317, and enhanced clinical observation cost $1,310-the cost of infants receiving intervention under categorical risk assessment was approximately twice that of the other 2 strategies. Results were robust to variations in data parameters. Conclusion. The neonatal sepsis calculator and enhanced clinical observation approaches may be preferred to categorical risk assessment as they reduce the number of infants receiving intervention and thus antibiotic exposure and associated costs. All 3 approaches have similar costs over all live births, and prior literature has indicated similar health outcomes. Inclusion of downstream effects of antibiotic exposure in the neonatal period should be evaluated within a cost-effectiveness analysis. Highlights Of the 3 approaches recommended by the American Academy of Pediatrics in 2018 to identify early-onset sepsis in infants born at ≥35 weeks, the categorical risk assessment approach leads to about twice as many infants receiving evaluation to rule out early-onset sepsis compared with the neonatal sepsis calculator and enhanced clinical observation approaches.While the hospital costs of the 3 approaches were similar over the entire population of live births, the neonatal sepsis calculator and enhanced clinical observation approaches reduce antibiotic exposure, neonatal intensive care unit admission, and hospital costs associated with interventions as part of the screening approach compared with the categorical risk assessment approach.
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Affiliation(s)
- Grace Guan
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Neha S. Joshi
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - Adam Frymoyer
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - Grace D. Achepohl
- Stanford Prevention Research Center, Stanford University, Palo Alto, CA, USA
| | - Rebecca Dang
- Department of Pediatrics, Center for Academic Medicine, Stanford University, Stanford, CA, USA
| | - N. Kenji Taylor
- Division of Primary Care & Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Roots Community Health Center, Oakland, CA, USA
- Intermountain Health Care, Intermountain Health Delivery Institute, Salt Lake City, UT, USA
| | - Joshua A. Salomon
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Jeremy D. Goldhaber-Fiebert
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
| | - Douglas K. Owens
- Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA
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Berardi A, Zinani I, Bedetti L, Vaccina E, Toschi A, Toni G, Lecis M, Leone F, Monari F, Cozzolino M, Zini T, Boncompagni A, Iughetti L, Miselli F, Lugli L. Should we give antibiotics to neonates with mild non-progressive symptoms? A comparison of serial clinical observation and the neonatal sepsis risk calculator. Front Pediatr 2022; 10:882416. [PMID: 35967559 PMCID: PMC9364607 DOI: 10.3389/fped.2022.882416] [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: 02/23/2022] [Accepted: 06/30/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To compare two strategies [the neonatal sepsis risk calculator (NSC) and the updated serial clinical observation approach (SCO)] for the management of asymptomatic neonates at risk of early-onset sepsis (EOS) and neonates with mild non-progressive symptoms in the first hours of life. METHODS This was a single-center, retrospective cohort study conducted over 15 months (01/01/2019-31/03/2020). All live births at ≥34 weeks of gestation were included. Infants were managed using SCO and decisions were compared with those retrospectively projected by the NSC. The proportion of infants recommended for antibiotics or laboratory testing was compared in both strategies. McNemar's non-parametric test was used to assess significant differences in matched proportions. RESULTS Among the 3,445 neonates (late-preterm, n = 178; full-term, n = 3,267) 262 (7.6%) presented with symptoms of suspected EOS. There were no cases of culture-proven EOS. Only 1.9% of the neonates were treated with antibiotics (median antibiotic treatment, 2 days) and 4.0% were evaluated. According to NSC, antibiotics would have been administered in 5.4% of infants (absolute difference between SCO and NSC, 3.51%; 95% CI, 3.14-3.71%; p <0.0001) and 5.6% of infants would have undergone "rule out sepsis" (absolute difference between SCO and NSC, 1.63%, 95% CI 1.10-2.05; p <0.0001). CONCLUSION SCO minimizes laboratory testing and unnecessary antibiotics in infants at risk of EOS or with mild non-progressive symptoms, without the risk of a worse neonatal outcome. The NSC recommends almost three times more antibiotics than the SCO without improving neonatal outcomes.
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Affiliation(s)
- Alberto Berardi
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Isotta Zinani
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Luca Bedetti
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy.,Doctorate School, Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Eleonora Vaccina
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Alessandra Toschi
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Greta Toni
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Marco Lecis
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Federica Leone
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francesca Monari
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Michela Cozzolino
- Obstetrics Unit, Mother Infant Department, University Hospital Policlinico of Modena, Modena, Italy
| | - Tommaso Zini
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Alessandra Boncompagni
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Post-Graduate School, Università degli Studi di Modena e Reggio Emilia, Modena, Italy.,Pediatric Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Francesca Miselli
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Licia Lugli
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
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