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俞 元, 陈 平. [Advances in clinical management of neonatal sepsis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:518-522. [PMID: 38802914 PMCID: PMC11135065 DOI: 10.7499/j.issn.1008-8830.2309145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/19/2024] [Indexed: 05/29/2024]
Abstract
Neonatal sepsis, as a significant cause of various complications and adverse outcomes in neonates, remains a serious health burden both domestically and internationally. Strategies such as antibiotic prophylaxis during delivery, the utilization of early-onset sepsis risk calculators, and quality improvement initiatives in neonatal wards are beneficial in alleviating the disease burden of neonatal sepsis. This paper provides a review of the epidemiology, risk factors, and recent advances in clinical management of neonatal sepsis.
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Bultmann CR, Qiu J, Belmonte B, Fairchild KD, Sullivan BA. Heart rate and oxygen saturation patterns in very low birth weight infants with early onset sepsis and histologic chorioamnionitis. J Neonatal Perinatal Med 2024; 17:209-215. [PMID: 38578905 DOI: 10.3233/npm-230093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Chorioamnionitis and early onset sepsis (EOS) in very low birth weight (VLBW,< 1500 g) infants may cause a systemic inflammatory response reflected in patterns of heart rate (HR) and oxygenation measured by pulse oximetry (SpO2). Identification of these patterns might inform decisions about duration of antibiotic therapy after birth. OBJECTIVE Compare early HR and SpO2 patterns in VLBW infants with or without early onset sepsis (EOS) or histologic chorioamnionitis (HC). STUDY DESIGN Retrospective study of placental pathology and HR and SpO2 in the first 72 h from birth in relation to EOS status for inborn VLBW NICU patients 2012-2019. RESULT Among 362 VLBW infants with HR and SpO2 data available, clinical, or culture-positive EOS occurred in 91/362 (25%) and HC in 81/355 (22%). In univariate analysis, EOS was associated with higher mean HR, lower mean SpO2, and less negative skewness of HR in the first 3 days after birth. HC was associated with higher standard deviation and skewness of HR but no difference in SpO2. In multivariable modeling, significant risk factors for EOS were mean HR, gestational age, HC, mean SpO2, and skewness of SpO2. CONCLUSION HR and SpO2 patterns differ shortly after birth in VLBW infants exposed to HC or with EOS, likely reflecting a systemic inflammatory response.
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Affiliation(s)
| | - Jiaxang Qiu
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Briana Belmonte
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Brynne A Sullivan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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Köstlin-Gille N, Serna-Higuita LM, Bubser C, Arand J, Haag L, Schwarz CE, Heideking M, Poets CF, Gille C. Early initiation of antibiotic therapy and short-term outcomes in preterm infants: a single-centre retrospective cohort analysis. Arch Dis Child Fetal Neonatal Ed 2023; 108:623-630. [PMID: 37137680 PMCID: PMC10646875 DOI: 10.1136/archdischild-2022-325113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Sepsis is one of the most important complications in preterm infants. For this reason, many such infants receive antibiotics during their hospital stay. However, early antibiotic therapy has also been associated with adverse outcome. It is yet largely unclear if the time of onset of antibiotic therapy influences the outcome. We here investigated whether the timing of initiation of antibiotic therapy plays a role in the association between antibiotic exposure and short-term outcome. METHODS Retrospective analysis of data from 1762 very low birthweight infants born in a German neonatal intensive care unit (NICU) between January 2004 and December 2021. RESULTS Antibiotics were administered to 1214 of the 1762 (68.9%) infants. In 973 (55.2%) of the 1762 of infants, antibiotic therapy was initiated within the first two postnatal days. Only 548 (31.1%) infants did not have any antibiotic prescription during their stay in the NICU. Antibiotic exposure at every timepoint was associated with an increased risk of all short-term outcomes analysed in univariable analyses. In multivariable analyses, initiation of antibiotic therapy within the first two postnatal days and initiation between postnatal days 3 and 6 was independently associated with an increased risk of developing bronchopulmonary dysplasia (BPD) (OR 3.1 and 2.8), while later initiation of antibiotic therapy was not. CONCLUSION Very early initiation of antibiotic therapy was associated with an increased risk of BPD. Due to the study design, no conclusions on causality can be drawn. If confirmed, our data suggest that an improved identification of infants at low risk of early-onset sepsis is needed to reduce antibiotic exposure.
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Affiliation(s)
| | - Lina Maria Serna-Higuita
- Department of Clinical Epidemiology and Applied Biostatistics, Eberhard Karls University, Tübingen, Germany
| | - Caren Bubser
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Joerg Arand
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Laura Haag
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | | | - Martin Heideking
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Christian F Poets
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
| | - Christian Gille
- Department of Neonatology, University of Tuebingen, Tubingen, Germany
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Daniels K, Arrieta A, Nieves DJ, Bhakta K, Tran MT, Osborne S, Morphew T. Ampicillin and Gentamicin Treatment for Early Onset Neonatal Sepsis: When One Size Does Not Fit All. Clin Pediatr (Phila) 2023; 62:1027-1031. [PMID: 36691803 DOI: 10.1177/00099228221150612] [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: 01/25/2023]
Abstract
Based on in vitro susceptibilities and the concern for emergence of resistance and long-term safety, ampicillin plus gentamicin remains the recommended antibiotic regimen for early onset neonatal sepsis. Our objective was to identify potential limitations of this regimen based on clinical and pathogen characteristics while minimizing risks associated with prolonged antibiotic exposure. We identified 43 gram-negative pathogens in 42 patients. Escherichia coli (E coli) occurred in 50% and Streptococcus agalactiae in 23.8% of patient. Ampicillin resistance was common, particularly in E coli (85.7%). Mortality was 23.8%, all due to E coli. We found that E coli is the most frequent pathogen and has a high mortality particularly in neonates < 1500 g; mortality is high with the current dosing strategy when E coli is resistant to ampicillin even when sensitive to gentamicin; resistance to gentamicin remains low but seems to be increasing while resistance to third-generation cephalosporins remains very low.
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Affiliation(s)
| | - Antonio Arrieta
- Pediatric Infectious Diseases, CHOC Children's Hospital, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Delma J Nieves
- Pediatric Infectious Diseases, CHOC Children's Hospital, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Kushal Bhakta
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
- Neonatology, CHOC Children's Hospital, Orange, CA, USA
| | - M Tuan Tran
- Pharmacy Services, CHOC Children's Hospital, Orange, CA, USA
| | | | - Tricia Morphew
- CHOC Research Institute, CHOC Children's Hospital, Orange, CA, USA
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魏 欣, 张 静, 郝 庆, 杜 延, 程 秀. [Establishment of a nomogram model for predicting the risk of early-onset sepsis in very preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:915-922. [PMID: 37718396 PMCID: PMC10511222 DOI: 10.7499/j.issn.1008-8830.2302002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES To identify risk factors associated with early-onset sepsis (EOS) in very preterm infants and develop a nomogram model for predicting the risk of EOS. METHODS A retrospective analysis was conducted on 344 very preterm infants delivered at the First Affiliated Hospital of Zhengzhou University and admitted to the Department of Neonatology between January 2020 and December 2022. These infants were randomly divided into a training set (241 infants) and a validating set (103 infants) in a 7:3 ratio. The training set was further divided into two groups based on the presence or absence of EOS: EOS (n=64) and non-EOS (n=177). Multivariate logistic regression analysis was performed to identify risk factors for EOS in the very preterm infants. The nomogram model was developed using R language and validated using the validating set. The discriminative ability, calibration, and clinical utility of the model were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis, respectively. RESULTS The multivariate logistic regression analysis revealed that gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis were risk factors for EOS in very preterm infants (P<0.05). The area under the ROC curve for the training set was 0.925 (95%CI: 0.888-0.963), and that for the validating set was 0.796 (95%CI: 0.694-0.898), confirming the model's good discrimination. The Hosmer-Lemeshow goodness-of-fit test suggested that the model was well-fitting (P=0.621). The calibration curve analysis and decision curve analysis demonstrated that the model had high predictive efficacy and clinical applicability. CONCLUSIONS Gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis are significantly associated with the development of EOS in very preterm infants.The nomogram model for predicting the risk of EOS in very preterm infants, constructed based on these factors, has high predictive efficacy and clinical applicability.
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Coggins SA, Willis Z, Benjamin DK, Mukhopadhyay S, Laughon M, Greenberg RG, Clark RH, Puopolo KM. Early antibiotic exposure in very-low birth weight infants and infection risk at 3-7 days after birth. J Perinatol 2023; 43:1158-1165. [PMID: 37491474 PMCID: PMC10529484 DOI: 10.1038/s41372-023-01737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To determine rates of late-onset infection (LOI) during postnatal days 3-7 among preterm infants, based on antibiotic exposure during days 0-2. STUDY DESIGN Retrospective cohort study of infants born <1500 grams and ≤30 weeks gestation, 2005-2018. We analyzed the incidence and microbiology of LOI at days 3-7 based on antibiotic exposure during postnatal days 0-2. RESULTS The cohort included 88,574 infants, of whom 85% were antibiotic-exposed. Fewer antibiotic-exposed compared to unexposed infants developed LOI (1.5% vs. 2.1%; adjusted hazard ratio, 0.28, 95% CI 0.24-0.33). Among antibiotic-exposed compared to unexposed infants, Gram-negative (38% vs. 28%, p = 0.002) and fungal (11% vs. 1%, p < 0.001) species were more commonly isolated, and gram-positive organisms (49% vs. 70%, p < 0.001) were less commonly isolated. CONCLUSIONS We observed low overall rates of LOI at days 3-7 after birth, but antibiotic exposure from birth was associated with lower rates, and with differing microbiology, compared to no exposure.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Zachary Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Coggins SA, Mukhopadhyay S, Triebwasser J, Downes KJ, Christie JD, Puopolo KM. Association of delivery risk phenotype with early-onset sepsis in preterm infants. J Perinatol 2023; 43:1166-1172. [PMID: 37543652 PMCID: PMC10530160 DOI: 10.1038/s41372-023-01743-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/18/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To determine delivery risk phenotype-specific incidence of early-onset sepsis (EOS) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born <35 weeks' gestation at four perinatal centers during 2017-2021. Infants were classified into one of six delivery risk phenotypes incorporating delivery mode, presence of labor, and duration of rupture of membranes (ROM). The primary outcome was EOS incidence within the overall cohort and each risk phenotype. RESULTS Among 2937 preterm infants, 21 had EOS (0.7%, or 7.1 cases/1000 preterm infants). The majority of EOS cases (13/21, 62%) occurred in the setting of prolonged ROM ≥ 18 h, with a phenotype incidence of 23.8 cases/1000 preterm infants. There were no EOS cases among infants born by cesarean section without ROM (with or without labor), nor via cesarean section with ROM < 18 h without labor. CONCLUSION Delivery risk phenotyping may inform EOS risk stratification in preterm infants.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jourdan Triebwasser
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Pantoja A, Sveum S, Frost S, Duran A, Burks J, Schernecke C, Feinberg M. New strategies to Reduce Unnecessary Antibiotic Use in the NICU: A Quality Improvement Initiative. Pediatr Qual Saf 2023; 8:e659. [PMID: 38571732 PMCID: PMC10990351 DOI: 10.1097/pq9.0000000000000659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/05/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Early-onset sepsis (EOS) and late-onset Sepsis (LOS) are common diagnoses entertained in sick newborns treated in neonatal intensive care units (NICUs), and antibiotics are the medications most prescribed in NICUs. Antibiotic stewardship programs have an important impact on limiting unnecessary antibiotic use. Methods Following the Model for Improvement, between 2/1/16 and 1/31/17, at a level 3 NICU, a multidisciplinary team implemented PDSA cycles to promote antibiotic stewardship practices for newborns at risk of EOS and LOS. The main goal was to decrease the antibiotic usage rate (AUR) safely. Primary strategies included discontinuing antibiotics within 24 hours of life if the newborn was stable, and the blood culture was negative for EOS and implementing an "antibiotic time-out" during rounds. Results For all newborns admitted to our NICU, the AUR decreased, for EOS from 137 to 32 days per 1000 patient days (77% reduction) and for LOS from 277 to 121 days per 1000 patient days (56% reduction). We demonstrated the sustainability of both EOS-AUR and LOS-AUR during the 2 years postcompletion of the intervention period. There were no adverse effects of reducing the AUR. Conclusion Interventions that reduce unnecessary antibiotic use in the NICU are safe and prevent excessive antibiotic exposure.
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Affiliation(s)
- Alfonso Pantoja
- From the Saint Joseph Hospital, Denver, Colo
- Colorado Permanente Medical Group, Denver, CO
| | - Scott Sveum
- From the Saint Joseph Hospital, Denver, Colo
- Vail Health, Frisco, CO
| | | | | | - Jeanne Burks
- From the Saint Joseph Hospital, Denver, Colo
- Envision Physician Services, Phoenix, AZ
| | - Christi Schernecke
- From the Saint Joseph Hospital, Denver, Colo
- Methodist Dallas Medical Center, Dallas TX
| | - Michelle Feinberg
- From the Saint Joseph Hospital, Denver, Colo
- Colorado Permanente Medical Group, Denver, CO
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Sourour W, Sanchez V, Sourour M, Burdine J, Lien ER, Nguyen D, Jain SK. The Association between Prolonged Antibiotic Use in Culture Negative Infants and Length of Hospital Stay and Total Hospital Costs. Am J Perinatol 2023; 40:525-531. [PMID: 33975363 DOI: 10.1055/s-0041-1729560] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to determine if prolonged antibiotic use at birth in neonates with a negative blood culture increases the total cost of hospital stay. STUDY DESIGN This was a retrospective study performed at a 60-bed level IV neonatal intensive care unit. Neonates born <30 weeks of gestation or <1,500 g between 2016 and 2018 who received antibiotics were included. A multivariate linear regression analysis was conducted to determine if clinical factors contributed to increased hospital cost or length of stay. RESULTS In total, 190 patients met inclusion criteria with 94 infants in the prolonged antibiotic group and 96 in the control group. Prolonged antibiotic use was associated with an increase length of hospital stay of approximately 31.87 days, resulting in a $69,946 increase in total cost of hospitalization. CONCLUSION Prolonged antibiotics in neonates with negative blood culture were associated with significantly longer hospital length of stay and increased total cost of hospitalization. KEY POINTS · Prolonged antibiotic use at birth is associated with prolonged hospital stay.. · Prolonged antibiotic use at birth is associated with increased cost of hospitalization.. · Prolonged antibiotic use at birth is associated with increased days on total parenteral nutrition.. · Prolonged antibiotic use at birth is associated with increased subsequent courses of antibiotics..
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Affiliation(s)
- Wesam Sourour
- Division of Pediatrics, University of Texas Medical Branch, Galveston, Texas
| | - Valeria Sanchez
- University of Texas Medical Branch School of Medicine, Galveston, Texas
| | - Michel Sourour
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Jordan Burdine
- Department of Pharmacy, University of Texas Medical Branch, Galveston, Texas
| | | | - Diana Nguyen
- Division of Pediatric Infectious Diseases, University of Texas Medical Branch, Galveston, Texas
| | - Sunil K Jain
- Division of Neonatology, University of Texas Medical Branch, Galveston, Texas
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Cuna A, Morowitz MJ, Sampath V. Early antibiotics and risk for necrotizing enterocolitis in premature infants: A narrative review. Front Pediatr 2023; 11:1112812. [PMID: 36865691 PMCID: PMC9971631 DOI: 10.3389/fped.2023.1112812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
While prompt initiation of antibiotics at birth due to concerns for early onset sepsis is common, it often leads to many preterm infants being exposed to treatment despite negative blood cultures. Such exposure to early antibiotics can impact the developing gut microbiome putting infants at increased risk of several diseases. Necrotizing enterocolitis (NEC), a devastating inflammatory bowel disease that affects preterm infants, is among the most widely studied neonatal disease that has been linked to early antibiotics. While some studies have demonstrated an increased risk of NEC, other studies have demonstrated seemingly contrary findings of decreased NEC with early antibiotics. Studies using animal models have also yielded differing findings of benefit vs. harm of early antibiotic exposure on subsequent NEC susceptibility. We thus sought to conduct this narrative review to help clarify the relationship between early antibiotics exposure and future risk of NEC in preterm infants. Our objectives are to: (1) summarize findings from human and animal studies that investigated the relationship between early antibiotics and NEC, (2) highlight important limitations of these studies, (3) explore potential mechanisms that can explain why early antibiotics may increase or decrease NEC risk, and (4) identify future directions for research.
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Affiliation(s)
- Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MOUnited States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MOUnited States
| | - Michael J. Morowitz
- Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PAUnited States
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MOUnited States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MOUnited States
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The impact of early empirical antibiotics treatment on clinical outcome of very preterm infants: a nationwide multicentre study in China. Ital J Pediatr 2023; 49:14. [PMID: 36698176 PMCID: PMC9878784 DOI: 10.1186/s13052-023-01414-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Infants with rule-out infections are responsible for the majority of empirical antibiotics treatment (EAT) in neonatal intensive care units (NICUs), particularly very preterm infants (VPIs). Antibiotic overuse has been linked to adverse outcomes. There is a paucity of data on the association between EAT and clinical outcomes (containing the nutritional outcomes) of VPIs without infection-related morbidities. METHODS Clinical data of VPIs admitted in 28 hospitals in 20 provinces of China from September 2019 to December 2020 were collected. EAT of VPIs was calculated as the number of days with initial usage in the first week after birth, and then categorized into 3 groups (antibiotic exposure: none, 1-4 days, and > 4 days). Clinical characteristics, nutritional status , and the short-term clinical outcomes among 3 groups were compared and analyzed. RESULTS In total, 1834 VPIs without infection-related morbidities in the first postnatal week were enrolled, including 152 cases (8.3%) without antibiotics, 374 cases (20.4%) with EAT ≤4 days and 1308 cases (71.3%) with EAT > 4 days. After adjusting for the confounding variables, longer duration of EAT was associated with decreased weight growth velocity and increased duration of reach of full enteral feeding in EAT > 4 days group (aβ: -4.83, 95% CI: - 6.12 ~ - 3.53; aβ: 2.77, 95% CI: 0.25 ~ 5.87, respectively) than those receiving no antibiotics. In addition, the risk of feeding intolerance (FI) in EAT > 4 days group was 4 times higher than that in non-antibiotic group (aOR: 4.14, 95%CI: 1.49 ~ 13.56) and 1.8 times higher than that in EAT ≤4 days group (aOR: 1.82, 95%CI: 1.08 ~ 3.17). EAT > 4 days was also a risk factor for greater than or equal to stage 2 necrotizing enterocolitis (NEC) than those who did not receive antibiotics (aOR: 7.68, 95%CI: 1.14 ~ 54.75) and those who received EAT ≤4 days antibiotics (aOR: 5.42, 95%CI: 1.94 ~ 14.80). CONCLUSIONS The EAT rate among uninfected VPIs was high in Chinese NICUs. Prolonged antibiotic exposure was associated with decreased weight growth velocity, longer duration of reach of full enteral feeding, increased risk of feeding intolerance and NEC ≥ stage 2. Future stewardship interventions to reduce EAT use should be designed and implemented.
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Ratridewi I, Amalia K, Huwae TECJ, Putera MA, Sulistijono E. Systemic Candidosis Diagnostic Test with Candida Score and Monocyte Count in Premature Infants with Late-Onset Sepsis: Research in Low Resources Country. RUSSIAN JOURNAL OF INFECTION AND IMMUNITY 2023. [DOI: 10.15789/2220-7619-scd-2012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Abstract
Introduction: Candida is the cause of most systemic fungal infections that plays a role in the pathophysiology of sepsis in newborns, especially in premature infants with late-onset sepsis. The candida score can be used to assess the occurrence of systemic candidosis where a candida score 2.5 can accurately identify patients who are at high risk for candidiasis infection. Monocytes also play an important role in preventing candida invasion.
Materials and methods: This study used a cross sectional research design. Data was collected from premature infants with late-onset sepsis being suspected of systemic candidosis in neonatology inpatient ward. It was submitted from the period of November-December 2021. It takes a minimum of 31 samples to meet the criteria to process and analyze the data. The data obtained were processed and analyzed using the Receiver Operating Characteristic (ROC) method to obtain the Area Under Curve (AUC) value. Based on the AUC curve, the search for the most optimal intersection is carried out to obtain the sensitivity and specificity values.
Results: Of the 31 research subjects, the number of subjects with positive PCR results was 27 (76.93%) while negative were 4 respondents (12.9%). The mean value of PCR density in the positive group of subjects was 76.93 and the range was 40.23 122.78. Meanwhile, in the group of subjects who were negative, the PCR density value was 0. The results of the candida score diagnostic test showed that the sensitivity obtained was 81%. Higher sensitivity and specificity 70% were found in the combined examination of candida scores and monocyte counts according to cut-off compared with separate examinations.
Conclusions: The combined examination of candida score and monocyte count can be used as a diagnostic test for systemic candidosis in premature infants with late-onset sepsis, and could be used to consider the initiation of empirical antifungal therapy, either prophylactically or therapeutically, especially in limited laboratory facilities in Indonesia.
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Fleiss N, Schwabenbauer K, Randis TM, Polin RA. What's new in the management of neonatal early-onset sepsis? Arch Dis Child Fetal Neonatal Ed 2023; 108:10-14. [PMID: 35618407 DOI: 10.1136/archdischild-2021-323532] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/06/2022] [Indexed: 11/03/2022]
Abstract
The expert guidelines highlighted in this review provide an evidence-based framework for approaching at-risk infants and allow for a more limited and standardised approach to antibiotic use. While these guidelines have significantly reduced antibiotic utilisation worldwide, optimally each unit would individualise their approach to early onset sepsis (EOS) based on the neonatal population they serve and available resources. As advancements in EOS research continue and limitations with sepsis prediction tools are addressed, it is inevitable that our risk stratification and management guidelines will become more precise.
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Affiliation(s)
- Noa Fleiss
- Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathleen Schwabenbauer
- Pediatrics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Tara M Randis
- Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Duggan HL, Chow SSW, Austin NC, Shah PS, Lui K, Tan K. Early-onset sepsis in very preterm neonates in Australia and New Zealand, 2007-2018. Arch Dis Child Fetal Neonatal Ed 2023; 108:31-37. [PMID: 35705325 DOI: 10.1136/archdischild-2021-323243] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the epidemiology and population trends of early-onset sepsis in very preterm neonates admitted to neonatal intensive care units (NICU) in Australia and New Zealand. DESIGN Retrospective observational cohort study using a dual-nation registry database. SETTING 29 NICUs that have contributed to the Australian and New Zealand Neonatal Network. PARTICIPANTS Neonates born at <32 weeks' gestation born between 2007 and 2018 and then admitted to a NICU. MAIN OUTCOME MEASURES Microorganism profiles, incidence, mortality and morbidity. RESULTS Over the 12-year period, 614 early-onset sepsis cases from 43 178 very preterm admissions (14.2/1000 admissions) were identified. The trends of early-onset sepsis incidence remained stable, varying between 9.8 and 19.4/1000 admissions (linear trend, p=0.56). The leading causative organisms were Escherichia coli (E. coli) (33.7%) followed by group B Streptococcus (GBS) (16.1%). The incidence of E. coli increased between 2007 (3.2/1000 admissions) and 2018 (8.3/1000 admissions; p=0.02). Neonates with E. coli had higher odds of mortality compared with those with GBS (OR=2.8, 95% CI 1.2 to 6.1). Mortality due to GBS decreased over the same period (2007: 0.6/1000 admissions, 2018: 0.0/1000 admissions; p=0.01). Early-onset sepsis tripled the odds of mortality (OR=3.0, 95% CI 2.4 to 3.7) and halved the odds of survival without morbidity (OR=0.5, 95% CI 0.4 to 0.6). CONCLUSION Early-onset sepsis remains an important condition among very preterm populations. Furthermore, E. coli is a dominant microorganism of very preterm early-onset sepsis in Australia and New Zealand. Rates of E. coli have been increasing in recent years, while GBS-associated mortality has decreased.
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Affiliation(s)
- Husharn L Duggan
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Sharon S W Chow
- Australia and New Zealand Neonatal Network, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicola C Austin
- Department of Paediatrics, Christchurch Women's Hospital, Christchurch, New Zealand
| | | | - Kei Lui
- Australia and New Zealand Neonatal Network, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Newborn Care, The Royal Hospital for Women, Newborn Intensive Care Unit, Randwick, New South Wales, Australia
| | - Kenneth Tan
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia .,Monash Newborn, Monash Health, Clayton, Victoria, Australia
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Mukhopadhyay S, Lee JJ, Hartman E, Woodford E, Dhudasia MB, Mattei LM, Daniel SG, Wade KC, Underwood MA, Bittinger K. Preterm infants at low risk for early-onset sepsis differ in early fecal microbiome assembly. Gut Microbes 2022; 14:2154091. [PMID: 36474348 PMCID: PMC9733690 DOI: 10.1080/19490976.2022.2154091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Antibiotics are administered near-universally to very low birth weight (VLBW) infants after birth for suspected early-onset sepsis (EOS). We previously identified a phenotypic group of VLBW infants, referred to as low-risk for EOS (LRE), whose risk of EOS is low enough to avoid routine antibiotic initiation. In this cohort study, we compared 18 such infants with 30 infants categorized as non-LRE to determine if the lower risk of pathogen transmission at birth is accompanied by differences in microbiome acquisition and development. We did shotgun metagenomic sequencing of 361 fecal samples obtained serially. LRE infants had a higher human-to-bacterial DNA ratio than non-LRE infants in fecal samples on days 1-3 after birth, confirming lower bacterial acquisition among LRE infants. The microbial diversity and composition in samples from days 4-7 differed between the groups with a predominance of Staphylococcus epidermidis in LRE infants and Enterobacteriaceae sp. in non-LRE infants. Compositional differences were congruent with the distribution of virulence factors and antibiotic resistant genes. After the first week, the overall composition was similar, but changes in relative abundance for several taxa with increasing age differed between groups. Of the nine late-onset bacteremia episodes, eight occurred in non-LRE infants. Species isolated from the blood culture was detected in the pre-antibiotic fecal samples of the infant for all episodes, though these species were also found in infants without bacteremia. In conclusion, LRE infants present a distinct pattern of microbiome development that is aligned with their low risk for EOS. Further investigation to determine the impact of these differences on later outcomes such as late-onset bacteremia is warranted.
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Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Sagori Mukhopadhyay Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Office 19-322, Philadelphia, PA19146, United States
| | - Jung-Jin Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Erica Hartman
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Emily Woodford
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Miren B. Dhudasia
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Lisa M. Mattei
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Scott G. Daniel
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Kelly C. Wade
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Mark A. Underwood
- Department of Pediatrics, University of California Davis, Sacramento, California, United States
| | - Kyle Bittinger
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States,Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States,CONTACT Kyle Bittinger CHOP Microbiome Center, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA19146, United States
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16
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Flannery DD, Puopolo KM, Hansen NI, Sánchez PJ, Stoll BJ. Neonatal infections: Insights from a multicenter longitudinal research collaborative. Semin Perinatol 2022; 46:151637. [PMID: 35864010 PMCID: PMC10959576 DOI: 10.1016/j.semperi.2022.151637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
For more than 30 years, the Neonatal Research Network (NRN) has conducted studies addressing the epidemiology of neonatal infections, including incidence, microbiology, maternal and neonatal risk factors, associated clinical findings, and outcomes. These studies have provided clinicians and policymakers critical data needed to inform national guidance for infection risk assessment and support daily practice. Further, NRN studies have prompted research into optimal approaches to infection diagnosis, treatment, and antimicrobial stewardship. In this article, we summarize the key findings of NRN infection-related studies, with an emphasis on those published in 2000 or later.
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Affiliation(s)
- Dustin D Flannery
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Karen M Puopolo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nellie I Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Barbara J Stoll
- Department of Pediatrics, Emory University, Atlanta, GA, USA
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Abstract
Early-onset sepsis (EOS) is a significant cause of morbidity and mortality among newborn infants, particularly among those born premature. The epidemiology of EOS is changing over time. Here, we highlight the most contemporary data informing the epidemiology of neonatal EOS, including incidence, microbiology, risk factors, and associated outcomes, with a focus on infants born in high-income countries during their birth hospitalization. We discuss approaches to risk assessment for EOS, summarizing national guidelines and comparing key differences between approaches for term and preterm infants. Lastly, we analyze contemporary antibiotic resistance data for EOS pathogens to inform optimal empiric treatment for EOS.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA
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18
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Danieli-Gruber S, Greenberg G, Shechter S, Romano A, Shmueli A, Barbash-Hazan S, Bardin R, Krispin E, Hadar E. Association between progesterone treatment and neonatal outcome in preterm births: a retrospective analysis. J OBSTET GYNAECOL 2022; 42:2826-2832. [PMID: 35972450 DOI: 10.1080/01443615.2022.2109950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This retrospective study was conducted to determine if infants born prematurely despite prophylactic maternal progesterone treatment during pregnancy may still benefit from its adjunct properties and have decreased neonatal complications. 248 women treated with vaginal/intramuscular progesterone during pregnancy and 2519 controls who gave birth to a preterm newborn (24 + 0-36 + 6 gestational weeks) at a tertiary medical centre in 2012-2019. The primary outcome measure was neonatal infectious composite outcome. Secondary outcome measures were other maternal and neonatal complications. Compared to controls, the study group was characterised by lower gestational age at birth (35.0 ± 2.66 vs. 36.0 ± 2.23 weeks, p < .001), lower birth weight (2294 vs. 2485 g, p < .001), higher rates of neonatal infectious composite outcome (27.82 vs. 21.36%, p = 0.024), NICU admission, periventricular leukomalacia, and mechanical ventilation. The higher neonatal infectious composite outcome is likely associated with the lower gestational age at birth in this high-risk group and not the progesterone treatment per se.IMPACT STATEMENTWhat is already known on this subject? Several randomised controlled trials have shown that progesterone administration in pregnancy significantly reduced the rate and complications of preterm birth. A recent study reported that vaginal administration of progesterone during pregnancy was more effective than intramuscular administration in decreasing vaginal group B Streptococcus (GBS) colonisation. This finding raises the question of whether progesterone treatment may have additional benefits besides preventing preterm birth and may reduce neonatal complication rate in preterm infants.What do the results of this study add? This is the first study examining the impact of gestational progesterone exposure on outcomes of preterm infants. The primary objective was a composite measure of infectious neonatal outcomes. Newborns who had progesterone exposure on average had lower gestational age, lower birth weight and higher neonatal infectious composite outcome. The significant difference is explained by lower gestational age.What are the implications of these findings for clinical practice and/or further research? Progesterone is widely used to prevent preterm birth, and may have important additive effects even when prematurity is not avoided. Although the findings did not support our initial hypothesis, they warrant further examination with larger cohorts.
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Affiliation(s)
- Shir Danieli-Gruber
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gal Greenberg
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shirley Shechter
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Romano
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Shmueli
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shiri Barbash-Hazan
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Bardin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Krispin
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Poggi C, Lucenteforte E, Petri D, De Masi S, Dani C. Presepsin for the Diagnosis of Neonatal Early-Onset Sepsis: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:750-758. [PMID: 35639395 PMCID: PMC9157383 DOI: 10.1001/jamapediatrics.2022.1647] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Neonatal early-onset sepsis (EOS) is a severe disease, particularly in preterm infants. Timely diagnosis can be challenging owing to unspecific presentation and questionable performance of the common markers of infection. Presepsin was recently proven to be a promising biomarker for the diagnosis of EOS. OBJECTIVE To assess presepsin accuracy for the diagnosis of EOS. DATA SOURCES PubMed Medline, EMBASE, Web of Science, and Google Scholar. No publication date restrictions were applied. The literature search was limited to the English language. Articles were checked for duplication. STUDY SELECTION Inclusion criteria were studies that (1) included term or preterm newborns (defined as newborns with gestational age ≥37 weeks or <37 weeks, respectively); (2) included a diagnosis of EOS, defined as culture-proven sepsis for primary analysis and as either clinical or culture-proven sepsis for secondary analysis; and (3) assessed presepsin values during the initial workup for suspected EOS. Exclusion criteria were studies that (1) did not include EOS cases; (2) lacked data on presepsin sensitivity and/or specificity; and (3) were case reports, commentaries, or reviews. Two independent reviewers performed the study selection. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed data extraction and quality assessment. Quality assessment was performed using the Quality Assessment for Studies of Diagnostic Accuracy 2 tool, and data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURES The outcomes of interest for both the primary and secondary analyses were presepsin sensitivity, specificity, and diagnostic odds ratio for the diagnosis of EOS. RESULTS A total of 12 studies of 245 (4.9%) met inclusion criteria for the primary analysis. Twenty-three studies of 245 (9.4%) met the inclusion criteria for the secondary analysis. In the primary analysis, among 12 studies and 828 newborns of any gestational age, pooled sensitivity and specificity were 0.93 (95% CI, 0.86-0.95) and 0.91 (95% CI, 0.85-0.95), respectively; pooled diagnostic odds ratio was 131.69 (95% CI, 54.93-310.94). Subgroup analysis showed that presepsin specificity was associated with the inclusion of only EOS or all neonatal sepsis. Presepsin accuracy was not associated with gestational age, measurement with chemiluminescence enzyme immunoassay or enzyme-linked immunosorbent assay testing, country where the study was performed, or risk of bias judgment. In the secondary analysis, among 23 studies and 1866 newborns, accuracy was significantly associated with only test type. CONCLUSIONS AND RELEVANCE Results of this systematic review and meta-analysis suggest that presepsin was an accurate biomarker of EOS. Clinical trials are warranted to assess its usefulness and safety to reduce early antibiotic exposure, particularly in preterm newborns.
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Affiliation(s)
- Chiara Poggi
- Neonatology and Neonatal Intensive Care, Department of Mother and Child Care, Careggi University Hospital, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Davide Petri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Carlo Dani
- Neonatology and Neonatal Intensive Care, Department of Mother and Child Care, Careggi University Hospital, Florence, Italy,Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
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20
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Utility of blood cultures in preterm infants born by cesarean delivery due to non-infectious maternal or fetal indications. J Perinatol 2022; 42:937-939. [PMID: 35459906 DOI: 10.1038/s41372-022-01405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/09/2022]
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Morowitz MJ, Katheria AC, Polin RA, Pace E, Huang DT, Chang CCH, Yabes JG. The NICU Antibiotics and Outcomes (NANO) trial: a randomized multicenter clinical trial assessing empiric antibiotics and clinical outcomes in newborn preterm infants. Trials 2022; 23:428. [PMID: 35606829 PMCID: PMC9125935 DOI: 10.1186/s13063-022-06352-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Early-onset sepsis is an important cause of neonatal morbidity and mortality in the preterm population. Infants perceived to be at increased risk for early-onset sepsis are often treated empirically with broad-spectrum antibiotics while awaiting confirmatory blood cultures, despite an overall incidence of early-onset sepsis of 2–3% among extremely-low-birthweight (ELBW) infants. Recent observational studies associate perinatal antibiotic use with an increased incidence of necrotizing enterocolitis, late-onset sepsis, and mortality among ELBW infants. Given currently available data and variability in clinical practice, we designed a prospective multi-institutional randomized controlled trial to determine the safety of early antibiotic use in ELBW infants. Methods The NICU Antibiotics and Outcomes (NANO) trial is a multicenter, double-blinded, randomized controlled trial. A sample of 802 ELBW preterm infants will undergo web-based stratified block randomization to receive empiric antibiotics (EA; ampicillin and gentamicin) or placebo during routine evaluation for early-onset sepsis. Participating sites will use preexisting institutional protocols for antibiotic dosage and duration. Infants born at participating sites with a gestational age of 29 weeks or less are eligible for enrollment. Exclusion criteria include maternal intrauterine infection, hemodynamic or respiratory instability, delivery by caesarean section for maternal indications without labor or prolonged rupture of membranes, and prior administration of antibiotics. The primary outcome is the composite incidence of necrotizing enterocolitis, late-onset sepsis, or death during participants’ index hospitalization. Maternal and infant samples will be collected longitudinally and assessed for differences in microbiome composition and diversity. Discussion The NANO trial is designed to compare the rate of adverse outcomes of EA use at birth versus placebo in ELBW preterm infants. If EA at birth worsens clinical outcomes, then the results of the trial may help providers decrease antibiotic utilization in the NICU and subsequently decrease the incidence of complications associated with early antibiotic use in ELBW infants. If we instead find that EA improve outcomes, then the trial will validate a longstanding clinical practice that has not previously been supported by high-quality data. Future studies will assess long-term clinical and microbial outcomes in infants who received empiric antibiotics following delivery. Trial registration Trial registration data: June 25, 2019 NCT03997266. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06352-3.
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Affiliation(s)
- Michael J Morowitz
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Rangos Research Center 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Anup C Katheria
- Division of Pediatrics, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, 92123, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University, New York, NY, 10032, USA
| | - Elizabeth Pace
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - David T Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Chung-Chou H Chang
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Johathan G Yabes
- Department of General Internal Medicine, University of Pittsburgh, Pittsburgh, USA
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[Effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:521-529. [PMID: 35644192 PMCID: PMC9154368 DOI: 10.7499/j.issn.1008-8830.2201016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To study the effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks. METHODS The medical data were retrospectively collected from 865 preterm infants with a gestational age of <35 weeks who were admitted to the Neonatal Intensive Care Unit of Xiangya Hospital of Central South University from January 1, 2014 to December 31, 2016. The improved antibiotic use strategy was implemented since January 1, 2015. According to the time of implementation, the infants were divided into three groups: pre-adjustment (January 1, 2014 to December 31, 2014; n=303), post-adjustment Ⅰ (January 1, 2015 to December 31, 2015; n=293), and post-adjustment Ⅱ (January 1, 2016 to December 31, 2016; n=269). The medical data of the three groups were compared. RESULTS There were no significant differences among the three groups in gestational age, proportion of small-for-gestational-age infants, sex, and method of birth (P>0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had a significant reduction in the rate of use of antibiotics and the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days or 4-7 days and a significant reduction in the proportion of infants with a duration of antibiotic use of >7 days in the early postnatal period (P<0.05). Compared with the post-adjustment Ⅰ group, the post-adjustment Ⅱ group had a significant reduction in the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days and a significant reduction in the proportion of infants with a duration of antibiotic use of 4-7 days or >7 days (P<0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had significantly shorter duration of parenteral nutrition and length of hospital stay (P<0.05). There were gradual reductions in the incidence rates of grade ≥Ⅲ intraventricular hemorrhage (IVH) and late-onset sepsis (LOS) after the adjustment of antibiotic use strategy. The multivariate logistic regression analysis showed that the adjustment of antibiotic use strategy had no effect on short-term adverse clinical outcomes, and antibiotic use for >7 days significantly increased the risk of adverse clinical outcomes (P<0.05). CONCLUSIONS It is feasible to reduce unnecessary antibiotic use by the improvement in antibiotic use strategy in preterm infants with a gestational age of <35 weeks, which can also shorten the duration of parenteral nutrition and the length of hospital stay and reduce the incidence rates of grade ≥Ⅲ IVH and LOS.
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23
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Stritzke A, Tierney A, Keister F, Srivastava A, Dersch-Mills D, Hamilton C, Lodha A, Abou Mehrem A. Antimicrobial Stewardship at Birth in Preterm Infants: Not Just About a Decrease! Pediatr Infect Dis J 2022; 41:394-400. [PMID: 35067640 DOI: 10.1097/inf.0000000000003462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early-onset sepsis results in increased morbidity and mortality in preterm infants. Antimicrobial Stewardship Programs (ASPs) address the need to balance adverse effects of antibiotic exposure with the need for empiric treatment for infants at the highest risk for early-onset sepsis. METHODS All preterm infants <34 weeks gestational age born during a 6-month period before (January 2017-June 2017) and a 6-month period after (January 2019-June 2019) implementation of ASP in May 2018 were reviewed. The presence of perinatal sepsis risk factors, eligibility for, versus treatment with initial empiric antibiotics was compared. RESULTS Our cohort comprised 479 infants with a mean of 30 weeks gestation and birth weight of 1400 g. Demographics were comparable, with more Cesarean section deliveries in the post-ASP cohort. Any sepsis risk factor was present in 73.6% versus 68.4% in the pre- versus post-ASP cohorts (P = 0.23). Fewer infants were treated with antibiotics in the later cohort (60.4%) compared with the earlier cohort (69.7%; P = 0.04). Despite the presence of risk factors (preterm labor in 93% and rupture of membranes in 60%), 42% of infants did not receive initial antibiotics. Twenty percent with no perinatal sepsis risk factors were deemed low-risk and not treated. CONCLUSIONS Implementation of a neonatal ASP decreased antibiotic initiation at birth. Antibiotic use decreased (appropriately) in the subgroup with no perinatal sepsis risk factors. Of concern, some infants were not treated despite risk factors, such as preterm labor/rupture of membrane. Neonatal ASP teams need to be aware of potentially unintended consequences of their initiatives.
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Affiliation(s)
- Amelie Stritzke
- From the Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary
- Alberta Health Services, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Canada
| | - Anne Tierney
- From the Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary
- Alberta Health Services, Alberta, Canada
| | - Faith Keister
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Ankur Srivastava
- From the Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary
- Alberta Health Services, Alberta, Canada
| | - Deonne Dersch-Mills
- Alberta Health Services, Alberta, Canada
- Alberta Children's Hospital, Pharmacy, Calgary, Alberta, Canada
| | | | - Abhay Lodha
- From the Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary
- Alberta Health Services, Alberta, Canada
| | - Ayman Abou Mehrem
- From the Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary
- Alberta Health Services, Alberta, Canada
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Letouzey M, Lorthe E, Marchand-Martin L, Kayem G, Charlier C, Butin M, Mitha A, Kaminski M, Benhammou V, Ancel PY, Boileau P, Foix-L'Hélias L. Early Antibiotic Exposure and Adverse Outcomes in Very Preterm Infants at Low Risk of Early-Onset Sepsis: The EPIPAGE-2 Cohort Study. J Pediatr 2022; 243:91-98.e4. [PMID: 34942178 DOI: 10.1016/j.jpeds.2021.11.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/06/2021] [Accepted: 11/21/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the association between early empirical antibiotics and neonatal adverse outcomes in very preterm infants without risk factors for early-onset sepsis (EOS). STUDY DESIGN This is a secondary analysis of the EPIPAGE-2 study, a prospective national population-based cohort that included all liveborn infants at 22-31 completed weeks of gestation in France in 2011. Infants at high risk of EOS (ie, born after preterm labor or preterm premature rupture of membranes or from a mother who had clinical chorioamnionitis or had received antibiotics during the last 72 hours) were excluded. Early antibiotic exposure was defined as antibiotic therapy started at day 0 or day 1 of life, irrespective of the duration and type of antibiotics. We compared treated and untreated patients using inverse probability of treatment weighting based on estimated propensity scores. RESULTS Among 648 very preterm infants at low risk of EOS, 173 (26.2%) had received early antibiotic treatment. Early antibiotic exposure was not associated with death or late-onset sepsis or necrotizing enterocolitis (OR, 1.04; 95% CI, 0.72-1.50); however, it was associated with higher odds of severe cerebral lesions (OR, 2.71; 95% CI, 1.25-5.86) and moderate-severe bronchopulmonary dysplasia (BPD) (OR, 2.30; 95% CI, 1.21-4.38). CONCLUSIONS Early empirical antibiotic therapy administrated in very preterm infants at low risk of EOS was associated with a higher risk of severe cerebral lesions and moderate-severe BPD.
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Affiliation(s)
- Mathilde Letouzey
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France; Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Poissy, France
| | - Elsa Lorthe
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France; Unit of Population Epidemiology, Department of Primary Care Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Laetitia Marchand-Martin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France
| | - Gilles Kayem
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France; Department of Gynecology and Obstetrics, Armand Trousseau Hospital, APHP, Paris Sorbonne University, Paris, France
| | - Caroline Charlier
- Division of Infectious Diseases and Tropical Medicine, Hôpital Université Necker-Enfants Malades, Université de Paris, APHP, Paris, France; Biology of Infection Unit, Institut Pasteur, French National Reference Center and WHO Collaborating Center for Listeria, Inserm U1117, Paris, France
| | - Marine Butin
- Department of Neonatal Pediatrics, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Ayoub Mitha
- Department of Neonatal Medicine, Jeanne de Flandre Hospital, CHRU Lille, Lille, France
| | - Monique Kaminski
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France
| | - Valerie Benhammou
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France
| | - Pierre-Yves Ancel
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France; URC-CIC P1419, Cochin Hotel-Dieu Hospital, APHP, Paris, France
| | - Pascal Boileau
- Department of Neonatal Pediatrics, Poissy Saint Germain Hospital, Poissy, France; Université Paris-Saclay, UVSQ, UFR Simone Veil Santé, Montigny Le Bretonneux, France
| | - Laurence Foix-L'Hélias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm, INRA, F-75004 Paris, France; Department of Neonatal Pediatrics, Armand Trousseau Hospital, APHP, Paris Sorbonne University, Paris, France
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25
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Sands K, Spiller OB, Thomson K, Portal EAR, Iregbu KC, Walsh TR. Early-Onset Neonatal Sepsis in Low- and Middle-Income Countries: Current Challenges and Future Opportunities. Infect Drug Resist 2022; 15:933-946. [PMID: 35299860 PMCID: PMC8921667 DOI: 10.2147/idr.s294156] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/17/2022] [Indexed: 12/18/2022] Open
Abstract
Neonatal sepsis is defined as a systemic infection within the first 28 days of life, with early-onset sepsis (EOS) occurring within the first 72h, although the definition of EOS varies in literature. Whilst the global incidence has dramatically reduced over the last decade, neonatal sepsis remains an important cause of neonatal mortality, highest in low- and middle-income countries (LMICs). Symptoms at the onset of neonatal sepsis can be subtle, and therefore EOS is often difficult to diagnose from clinical presentation and laboratory testing and blood cultures are not always conclusive or accessible, especially in resource limited countries. Although the World Health Organisation (WHO) currently advocates a ß-lactam, and gentamicin for first line treatment, availability and cost influence the empirical antibiotic therapy administered. Antibiotic treatment of neonatal sepsis in LMICs is highly variable, partially caused by factors such as cost of antibiotics (and who pays for them) and access to certain antibiotics. Antimicrobial resistance (AMR) has increased considerably over the past decade and this review discusses current microbiology data available in the context of the diagnosis, and treatment for EOS. Importantly, this review highlights a large variability in data availability, methodology, availability of diagnostics, and aetiology of sepsis pathogens.
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Affiliation(s)
- Kirsty Sands
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Owen B Spiller
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Kathryn Thomson
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | | | | | - Timothy R Walsh
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
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26
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Capin I, Hinds A, Vomero B, Roth P, Blau J. Are Early-Onset Sepsis Evaluations and Empiric Antibiotics Mandatory for All Neonates Admitted with Respiratory Distress? Am J Perinatol 2022; 39:444-448. [PMID: 32947642 DOI: 10.1055/s-0040-1717070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the success and safety of an antimicrobial stewardship protocol for neonates admitted with respiratory distress at birth. STUDY DESIGN A retrospective cohort analysis of all infants admitted to the neonatal intensive care unit (NICU) with respiratory distress from January 2013 to February 2018 was conducted. In April 2016, an antimicrobial stewardship protocol was implemented, dividing neonates into two groups: maternal indications for delivery (no infectious risk factors for early-onset sepsis [EOS]) and fetal indications (risk factors present) for delivery. Neonates with risk factors for EOS were started on empiric antibiotics, those who lacked risk factors were observed. Paired sample t-test and descriptive statistics were used to compare the pre- and postprotocol implementation. RESULTS There were no missed cases of EOS in our study. Management with empiric antibiotics decreased from 95 to 41% of neonates with respiratory distress after initiation of the protocol. Newborns with a lower mean (±standard errors of the mean [SEM]) gestational age were more likely to receive empiric antibiotics (35.1 ± 0.4 [range: 23-42 weeks] vs. 37.7 ± 0.2 weeks [range: 24-42 weeks]; p < 0.05). Similar findings were seen for neonates with lower mean birth weights (2,627 ± 77 [range: 390-5,440 g] vs. 3,078 ± 51 g [range: 620-6,260 g]; p < 0.05). CONCLUSION The antibiotic stewardship protocol safely reduces the administration of empiric antibiotics to symptomatic neonates without missing any cases of sepsis. KEY POINTS · Newborns born with respiratory distress often receive broad-spectrum antibiotics upon NICU admission.. · An antibiotic stewardship program was created for this population and considered perinatal risk factors for sepsis when determining whether antibiotics were indicated.. · This antibiotic stewardship program was safe and effective, significantly reducing antibiotic use without missing any cases of sepsis..
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Affiliation(s)
- Ivana Capin
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Autumn Hinds
- SUNY Downstate College of Medicine, Brooklyn, New York
| | - Bridgit Vomero
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Philip Roth
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jonathan Blau
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Flannery DD, Mukhopadhyay S, Morales KH, Dhudasia MB, Passarella M, Gerber JS, Puopolo KM. Delivery Characteristics and the Risk of Early-Onset Neonatal Sepsis. Pediatrics 2022; 149:184465. [PMID: 35022750 PMCID: PMC9648068 DOI: 10.1542/peds.2021-052900] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Multiple strategies are used to identify newborn infants at high risk of culture-confirmed early-onset sepsis (EOS). Delivery characteristics have been used to identify preterm infants at lowest risk of infection to guide initiation of empirical antibiotics. Our objectives were to identify term and preterm infants at lowest risk of EOS using delivery characteristics and to determine antibiotic use among them. METHODS This was a retrospective cohort study of term and preterm infants born January 1, 2009 to December 31, 2014, with blood culture with or without cerebrospinal fluid culture obtained ≤72 hours after birth. Criteria for determining low EOS risk included: cesarean delivery, without labor or membrane rupture before delivery, and no antepartum concern for intraamniotic infection or nonreassuring fetal status. We determined the association between these characteristics, incidence of EOS, and antibiotic duration among infants without EOS. RESULTS Among 53 575 births, 7549 infants (14.1%) were evaluated and 41 (0.5%) of those evaluated had EOS. Low-risk delivery characteristics were present for 1121 (14.8%) evaluated infants, and none had EOS. Whereas antibiotics were initiated in a lower proportion of these infants (80.4% vs 91.0%, P < .001), duration of antibiotics administered to infants born with and without low-risk characteristics was not different (adjusted difference 0.6 hours, 95% CI [-3.8, 5.1]). CONCLUSIONS Risk of EOS among infants with low-risk delivery characteristics is extremely low. Despite this, a substantial proportion of these infants are administered antibiotics. Delivery characteristics should inform empirical antibiotic management decisions among infants born at all gestational ages.
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Affiliation(s)
- Dustin D. Flannery
- Center for Pediatric Clinical Effectiveness,Divisions of Neonatology,Center for Clinical Epidemiology and Biostatistics,Department of Pediatrics,Address correspondence to Dustin D. Flannery, DO, MSCE,
Children’s Hospital of Philadelphia Newborn Care at Pennsylvania
Hospital, 800 Spruce St, Philadelphia, PA 19107. E-mail:
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness,Divisions of Neonatology,Department of Pediatrics
| | - Knashawn H. Morales
- Center for Clinical Epidemiology and Biostatistics,Department of Biostatistics, Epidemiology &
Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia,
Pennsylvania
| | - Miren B. Dhudasia
- Center for Pediatric Clinical Effectiveness,Divisions of Neonatology
| | | | - Jeffrey S. Gerber
- Center for Pediatric Clinical Effectiveness,Infectious Diseases, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics,Department of Pediatrics
| | - Karen M. Puopolo
- Center for Pediatric Clinical Effectiveness,Divisions of Neonatology,Department of Pediatrics
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28
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Managing antibiotics wisely in a neonatal intensive care unit in a low resource setting. J Perinatol 2022; 42:965-970. [PMID: 35459905 PMCID: PMC9023725 DOI: 10.1038/s41372-022-01388-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Unnecessary early antibiotic exposure is deleterious, it may induce the selection of multi-drug-resistant organisms. The objective of this project was to decrease antibiotic exposure of newborns admitted to the neonatal intensive care unit at Hospital Cayetano Heredia, a level 3 unit in Lima, Peru. METHODS Quality improvement project in which we implemented an antibiotic stewardship program for early onset sepsis in the neonatal intensive care unit. Primary outcome measure was antibiotic usage rate, total number of days infants were exposed to antibacterial agents divided by 1000 patient-days. RESULTS Antibiotic usage rate declined from 291/1000 patient-days to 82/1000 patient-days during the last months of 2020, representing a total decrease of 65.1%. CONCLUSIONS Antibiotic stewardship for early-onset sepsis implemented in a perinatal center like ours is effective, appears to be safe and results in a sustained and significant decrease in the use of antibiotics for early-onset sepsis.
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29
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Morales-Betancourt C, De la Cruz-Bértolo J, Muñoz-Amat B, Bergón-Sendín E, Pallás-Alonso C. Reducing Early Antibiotic Use: A Quality Improvement Initiative in a Level III Neonatal Intensive Care Unit. Front Pediatr 2022; 10:913175. [PMID: 35712636 PMCID: PMC9192948 DOI: 10.3389/fped.2022.913175] [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: 04/05/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
UNLABELLED Antibiotic burden is a critical issue in neonatal intensive care units (NICU) and antibiotic use is considered a quality indicator of neonatal care. Our aim was to optimize antibiotic use through a quality improvement (QI) initiative that included revision of departmental protocols and implementation of a surveillance system based on process indicators. METHODS This is descriptive study of a cohort of all very low birth weight (VLBW) infants admitted to the NICU from 2014 to 2019. A series of QI interventions were made during the study period and included departmental protocols and the implementation of a surveillance system based on process indicators. The primary outcome was the percentage of VLBW infants who had received early antibiotics (ampicillin, gentamicin, or cefotaxime on the day of birth or day 1 or 2 after birth), antibiotics for longer than 3 days (despite negative blood culture), or no antibiotics. RESULTS During the study period, a significant relative reduction was seen in the proportion of VLBW infants administered early antibiotics (46%; p < 0.01) and in infants provided antibiotics for longer than 3 days (90%; p < 0.01). Additionally, the percentage of VLBW with "no antibiotics" during their NICU stay increased fivefold (6 to 30%; p < 0.001). CONCLUSIONS In our NICU, the implementation of a QI initiative that is based on affordable methods to track process indicators and evaluate the results led into a significant reduction in antibiotic exposure in VLBW infants. This approach is easy to implement in other NICUs as well.
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Affiliation(s)
| | | | - Bárbara Muñoz-Amat
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain
| | - Elena Bergón-Sendín
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain.,Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Carmen Pallás-Alonso
- Department of Neonatology, 12 de Octubre University Hospital, Madrid, Spain.,Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), Instituto de Salud Carlos III, Madrid, Spain
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30
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Neonatal blood culture inoculant volume: feasibility and challenges. Pediatr Res 2021; 90:1086-1092. [PMID: 33824451 PMCID: PMC8492767 DOI: 10.1038/s41390-021-01484-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Clinicians often express concerns about poor sensitivity of blood cultures in neonates resulting from inadequate inoculant volumes. Our objective was to determine the inoculant volume sent for neonatal sepsis evaluations and identify areas of improvement. METHODS Single-center prospective observational study of infants undergoing sepsis evaluation. Blood volume was determined by clinician documentation over 21 months, and additionally by weighing culture bottles during 12 months. Adequate volume was defined as ≥1 mL total inoculant per evaluation. For first-time evaluations, local guidelines recommend sending an aerobic-anaerobic pair with 1 mL inoculant in each. RESULTS There were 987 evaluations in 788 infants. Clinicians reported ≥1 mL total inoculant in 96.9% evaluations. Among 544 evaluations where bottles were weighed, 93.4% had ≥1 mL total inoculant. Very low birth weight infants undergoing evaluations >7 days after birth had the highest proportion of inadequate inoculants (14.4%). Only 3/544 evaluations and 26/1011 bottles had total inoculant <0.5 mL. Ninety evaluations had <1 mL in both aerobic and anaerobic bottles despite a total inoculant volume that allowed inoculation of ≥1 mL in one of the bottles. CONCLUSIONS Obtaining recommended inoculant volumes is feasible in majority of neonates. Measuring inoculant volumes can focus improvement efforts and improve test reliability. IMPACT Clinicians express concern about the unreliability of neonatal blood cultures because of inadequate inoculant volume. We investigated over 900 evaluations and found >90% of evaluations have ≥1 mL inoculant. Monitoring adequacy of blood culture technique can identify areas of improvement and may allay concerns about blood culture reliability. Current recommendations for adequate inoculant volume for blood cultures are met in a majority of neonates. Areas of improvement include preterm late-onset sepsis evaluations and distribution techniques during inoculation.
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Flannery DD, Edwards EM, Puopolo KM, Horbar JD. Early-Onset Sepsis Among Very Preterm Infants. Pediatrics 2021; 148:peds.2021-052456. [PMID: 34493539 DOI: 10.1542/peds.2021-052456] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the epidemiology and microbiology of early-onset sepsis (EOS) among very preterm infants using a nationally representative cohort from academic and community hospitals to inform empirical antibiotic guidance, highlight risk factors for infection, and aid in prognostication for infected infants. METHODS Prospective observational study of very preterm infants born weighing 401 to 1500 g or at 22 to 29 weeks' gestational age from January 2018 to December 2019 in 753 Vermont Oxford Network centers. EOS was defined as a culture-confirmed bacterial infection of the blood or cerebrospinal fluid in the 3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without EOS. RESULTS Of 84 333 included infants, 1139 had EOS for an incidence rate of 13.5 per 1000 very preterm births (99% confidence interval [CI] 12.5-14.6). Escherichia coli (538 of 1158; 46.5%) and group B Streptococcus (218 of 1158; 18.8%) were the most common pathogens. Infected infants had longer lengths of stay (median 92 vs 66 days) and lower rates of survival (67.5% vs 90.4%; adjusted risk ratio 0.82 [95% CI 0.79-0.85]) and of survival without morbidity (26.1% vs 59.4%; adjusted risk ratio 0.66 [95% CI 0.60-0.72]). CONCLUSIONS In a nationally representative sample of very preterm infants with EOS from 2018 to 2019, approximately one-third of isolates were neither group B Streptococcus nor E coli. Three-quarters of all infected infants either died or survived with a major medical morbidity. The profoundly negative impact of EOS on very preterm infants highlights the need for novel preventive strategies.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erika M Edwards
- Department of Pediatrics, Larner College of Medicine.,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont.,Vermont Oxford Network, Burlington, Vermont
| | - Karen M Puopolo
- Division of Neonatology.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey D Horbar
- Department of Pediatrics, Larner College of Medicine.,Vermont Oxford Network, Burlington, Vermont
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32
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Mukhopadhyay S, Underwood MA. Phenotyping preterm infants at birth to predict infection risk. Pediatr Res 2021; 90:508-509. [PMID: 34099853 DOI: 10.1038/s41390-021-01603-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 03/31/2021] [Accepted: 05/24/2021] [Indexed: 01/29/2023]
Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Mark A Underwood
- Division of Neonatology, Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA, USA
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[Clinical features of very preterm infants with prelabor rupture of membranes and predictive factors for major adverse outcomes]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 34130778 PMCID: PMC8214004 DOI: 10.7499/j.issn.1008-8830.2012177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the clinical features of very preterm infants with prelabor rupture of membranes (PROM) and predictive factors for early-onset sepsis (EOS) and death. METHODS A retrospective analysis was performed for the clinical data of the very preterm infants with PROM (with a gestational age of < 32 weeks) who were admitted to the neonatal intensive care unit from January 2018 to May 2020. According to the time from membrane rupture to delivery, the infants were divided into four groups: < 18 hours (n=107), 18 hours to < 3 days (n=111), 3 days to < 14 days (n=144), and ≥ 14 days (n=37). According to the presence or absence of EOS, the infants were divided into EOS (n=42) and non-EOS groups (n=357). According to the survival state, the infants were divided into a survival group (n=359) and a death group (n=40). Clinical features were analyzed for very preterm infants with different times of PROM. A multivariate logistic regression analysis was used to investigate the predictive factors for EOS and death in very preterm infants with PROM. RESULTS There was no significant difference in the incidence rates of major neonatal complications and mortality rate among the very preterm infants with different times of PROM (P > 0.05). Birth weight < 1 000 g (OR=4.353, P=0.042), grade Ⅲ amniotic fluid contamination (OR=4.132, P=0.032), and grade Ⅲ-Ⅳ respiratory distress syndrome (RDS) (OR=2.528, P=0.021) were predictive factors for EOS in very preterm infants with PROM. Lower birth weights (< 1 000 g or 1 000-1 499 g; OR=11.267 and 3.456 respectively; P=0.004 and 0.050 respectively), grade Ⅲ-Ⅳ RDS (OR=5.572, P < 0.001), and neonatal sepsis (OR=2.631, P=0.012) were predictive factors for death in very preterm infants with PROM. CONCLUSIONS Prolonged PROM does not increase the incidence of neonatal complications and mortality in very preterm infants. Adverse outcomes of very preterm infants with PROM are mainly associated with lower birth weights, lung immaturity, and systemic infection.
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Abstract
Antibiotics are extensively and inconsistently prescribed in neonatal ICUs, and usage does not correlate with rates of culture positive sepsis. There is mounting data describing the short and long-term adverse effects associated with antibiotic overuse in neonates, including the increased burden of multi-drug resistant organisms. Currently there is considerable variation in antibiotic prescribing practice among neonatologists. Applying the practice of antibiotic stewardship in the NICU is crucial for standardizing antibiotic use and improving outcomes in this population. Several approaches have been proposed to identify neonatal sepsis, with the hope of reducing antibiotic utilization. These strategies all have their limitations, and often include laboratory testing and treatment of well-appearing, non-septic, infants. A conservative "watch and wait" algorithm is suggested as an alternative method for when to initiate antibiotics. This observational approach relies on availability of trained personnel able to examine infants at specified intervals, without delaying antibiotics, should signs of sepsis arise.
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Affiliation(s)
- Noa Fleiss
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas A Hooven
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Richard A Polin
- Department of Pediatrics, Columbia University School of Medicine, New York City, NY, USA.
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35
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董 会, 宋 娟, 决 珍, 位 乐, 李 文, 周 竹. [Clinical features of very preterm infants with prelabor rupture of membranes and predictive factors for major adverse outcomes]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:575-581. [PMID: 34130778 PMCID: PMC8214004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/30/2021] [Indexed: 09/21/2023]
Abstract
OBJECTIVE To study the clinical features of very preterm infants with prelabor rupture of membranes (PROM) and predictive factors for early-onset sepsis (EOS) and death. METHODS A retrospective analysis was performed for the clinical data of the very preterm infants with PROM (with a gestational age of < 32 weeks) who were admitted to the neonatal intensive care unit from January 2018 to May 2020. According to the time from membrane rupture to delivery, the infants were divided into four groups: < 18 hours (n=107), 18 hours to < 3 days (n=111), 3 days to < 14 days (n=144), and ≥ 14 days (n=37). According to the presence or absence of EOS, the infants were divided into EOS (n=42) and non-EOS groups (n=357). According to the survival state, the infants were divided into a survival group (n=359) and a death group (n=40). Clinical features were analyzed for very preterm infants with different times of PROM. A multivariate logistic regression analysis was used to investigate the predictive factors for EOS and death in very preterm infants with PROM. RESULTS There was no significant difference in the incidence rates of major neonatal complications and mortality rate among the very preterm infants with different times of PROM (P > 0.05). Birth weight < 1 000 g (OR=4.353, P=0.042), grade Ⅲ amniotic fluid contamination (OR=4.132, P=0.032), and grade Ⅲ-Ⅳ respiratory distress syndrome (RDS) (OR=2.528, P=0.021) were predictive factors for EOS in very preterm infants with PROM. Lower birth weights (< 1 000 g or 1 000-1 499 g; OR=11.267 and 3.456 respectively; P=0.004 and 0.050 respectively), grade Ⅲ-Ⅳ RDS (OR=5.572, P < 0.001), and neonatal sepsis (OR=2.631, P=0.012) were predictive factors for death in very preterm infants with PROM. CONCLUSIONS Prolonged PROM does not increase the incidence of neonatal complications and mortality in very preterm infants. Adverse outcomes of very preterm infants with PROM are mainly associated with lower birth weights, lung immaturity, and systemic infection.
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Affiliation(s)
- 会敏 董
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
| | - 娟 宋
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
| | - 珍珍 决
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
| | - 乐乐 位
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
| | - 文冬 李
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
| | - 竹叶 周
- />郑州大学第三附属医院新生儿科/河南省小儿脑损伤重点实验室/河南省儿科疾病临床医学研究中心, 河南郑州 450052Department of Neonatology, Third Affiliated Hospital of Zhengzhou University/Henan Key Laboratory of Child Brain Injury/Henan Pediatric Clinical Research Center, Zhengzhou 450052, China
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36
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Weijden BM, Achten NB, Bekhof J, Evers EE, Berk M, Kamps AW, Rijpert M, ten Tusscher GW, Houten MA, Plötz FB. Multicentre study found that adherence to national antibiotic recommendations for neonatal early-onset sepsis was low. Acta Paediatr 2021; 110:791-798. [PMID: 32686180 PMCID: PMC7984438 DOI: 10.1111/apa.15488] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/01/2020] [Accepted: 07/14/2020] [Indexed: 01/21/2023]
Abstract
Aim Our aim was to evaluate adherence to the Dutch neonatal early‐onset sepsis (EOS) guidelines, adapted from UK guidance. We also looked at the effect on antibiotic recommendations and duration. Method This was a multicentre, prospective observational cross‐sectional study carried out in seven hospitals in the Netherlands between 1 September 2018 and 1 November 2019. We enrolled 1024 neonates born at 32 weeks of gestation or later if they demonstrated at least one EOS risk factor or clinical signs of infection. Results The Dutch guidelines recommended antibiotic treatment for 438/1024 (42.8%) of the neonates designated at risk, but only 186/438 (42.5%) received antibiotics. The guidelines advised withholding antibiotics for 586/1024 (57.2%) of neonates and in 570/586 (97.3%) cases the clinicians adhered to this recommendation. Blood cultures were obtained for 182/186 (97.8%) infants who started antibiotics and only four were positive, for group B streptococci. Antibiotic treatment was continued for more than 3 days in 56/178 (31.5%) neonates, despite a negative blood culture. Conclusion Low adherence to the Dutch guidelines meant that the majority of neonates did not receive the antibiotic treatment that was recommended, while some antibiotic use was prolonged despite negative blood cultures. The guidelines need to be revised.
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Affiliation(s)
- Bo M. Weijden
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
| | - Niek B. Achten
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
- Department of Paediatrics Emma Children's Hospital Amsterdam UMC Amsterdam The Netherlands
| | - Jolita Bekhof
- Department of Paediatrics Isala Hospital Zwolle The Netherlands
| | - Esther E. Evers
- Department of Paediatrics Isala Hospital Zwolle The Netherlands
| | - Mylène Berk
- Department of Paediatrics Spaarne Hospital Haarlem The Netherlands
| | - Arvid W.A. Kamps
- Department of Paediatrics Martini Hospital Groningen The Netherlands
| | - Maarten Rijpert
- Department of Paediatrics Zaans Medical Centre Zaandam The Netherlands
| | | | | | - Frans B. Plötz
- Department of Paediatrics Tergooi Hospital Blaricum The Netherlands
- Department of Paediatrics Emma Children's Hospital Amsterdam UMC Amsterdam The Netherlands
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37
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Dhudasia MB, Flannery DD, Pfeifer MR, Puopolo KM. Updated Guidance: Prevention and Management of Perinatal Group B Streptococcus Infection. Neoreviews 2021; 22:e177-e188. [PMID: 33649090 DOI: 10.1542/neo.22-3-e177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Group B Streptococcus (GBS) remains the most common cause of neonatal early-onset sepsis among term infants and a major cause of late-onset sepsis among both term and preterm infants. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists published separate but aligned guidelines in 2019 and 2020 for the prevention and management of perinatal GBS disease. Together, these replace prior consensus guidelines provided by the Centers for Disease Control and Prevention. Maternal intrapartum antibiotic prophylaxis based on antenatal screening for GBS colonization remains the primary recommended approach to prevent perinatal GBS disease, though the optimal window for screening is changed to 36 0/7 to 37 6/7 weeks of gestation rather than beginning at 35 0/7 weeks' gestation. Penicillin, ampicillin, or cefazolin are recommended for prophylaxis, with clindamycin and vancomycin reserved for cases of significant maternal penicillin allergy. Pregnant women with a history of penicillin allergy are now recommended to undergo skin testing, because confirmation of or delabeling from a penicillin allergy can provide both short- and long-term health benefits. Aligned with the American Academy of Pediatrics recommendations for evaluating newborns for all causes of early-onset sepsis, separate consideration should be given to infants born at less than 35 weeks' and more than or equal to 35 weeks' gestation when performing GBS risk assessment. Empiric antibiotics are recommended for infants at high risk for GBS early-onset disease. Although intrapartum antibiotic prophylaxis is effective in preventing GBS early-onset disease, currently there is no approach for the prevention of GBS late-onset disease.
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Affiliation(s)
- Miren B Dhudasia
- Division of Neonatology and.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Dustin D Flannery
- Division of Neonatology and.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Karen M Puopolo
- Division of Neonatology and.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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38
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Epidemiology of Early and Late Onset Neonatal Sepsis in Very Low Birthweight Infants: Data From the German Neonatal Network. Pediatr Infect Dis J 2021; 40:255-259. [PMID: 33538544 DOI: 10.1097/inf.0000000000002976] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sepsis is a major cause of death in neonates. Knowledge about epidemiology, risk factors, causative pathogens and outcome of neonatal sepsis is important to improve neonatal care. For Germany, only few data on neonatal sepsis in very low birth weight (VLBW) infants exist. METHODS Data from 14,926 preterm infants with birth weight <1500 g and gestational age between 22 0/7 weeks and 31 6/7 collected between January 2009 and December 2017 were analyzed for frequency of early-onset sepsis (EOS) and late-onset sepsis (LOS) and for causative pathogens. Risk factors for the development of EOS and LOS and outcomes after EOS and LOS were analyzed by multivariate logistic regression models. RESULTS EOS occurred in 1.1% of infants and LOS in 11.9%. Escherichia coli was the most common pathogen in EOS, coagulase-negative staphylococci in LOS. Multidrug-resistant organisms were detected in 8.4% of EOS and 3.9% of LOS cases. Risk factors for EOS were lower gestational age, intra-amniotic infection and spontaneous delivery. Risk factors for LOS were lower gestational age, small for gestational age, central lines, endotracheal ventilation and history of EOS. Both EOS and LOS were independently associated with adverse neonatal outcome. CONCLUSIONS These data from a large German neonatal cohort confirm neonatal sepsis as the most common cause of morbidity and mortality in VLBW infants, as well as E. coli and coagulase-negative staphylococci as the most prevalent pathogens. Multidisciplinary approaches such as antibiotic stewardship, hygiene and feeding strategies are necessary to further reduce the burden of sepsis in VLBW infants.
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Garber SJ, Dhudasia MB, Flannery DD, Passarella MR, Puopolo KM, Mukhopadhyay S. Delivery-based criteria for empiric antibiotic administration among preterm infants. J Perinatol 2021; 41:255-262. [PMID: 32792629 PMCID: PMC7881045 DOI: 10.1038/s41372-020-00784-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine impact of using delivery criteria to initiate antibiotics among very low birth weight (VLBW) and extremely low birth weight (ELBW) infants. STUDY DESIGN: Single site cohort study from 01/01/2009 to 01/31/2020. After 04/2017, infants delivered by Cesarean section, without labor or membrane rupture were categorized as low-risk for early-onset infection and managed without empiric antibiotics. We determined effect of this guideline by pre-post, and interrupted time-series analyses. RESULTS After 04/2017, antibiotic initiation ≤3 days decreased among low-risk VLBW (62% vs. 13%, p < 0.001) and low-risk ELBW (88% vs. 21%, p < 0.001) infants. In time series analysis, guideline was associated with decreased initiation among low-risk ELBW infants. In contrast, low-risk VLBW infants demonstrated decreased antibiotic initiation throughout study period. Incidence of confirmed infection, death, or transfer ≤7 days age was unchanged. CONCLUSION Delivery criteria may be used to optimize early antibiotic initiation among preterm infants without short-term increase in adverse outcomes.
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Affiliation(s)
- Samuel J Garber
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Miren B Dhudasia
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Molly R Passarella
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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40
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Martin-Mons S, Lorrain S, Iacobelli S, Gouyon B, Gouyon JB. Antibiotics Prescription Over Three Years in a French Benchmarking Network of 23 Level 3 Neonatal Wards. Front Pharmacol 2021; 11:585018. [PMID: 33568992 PMCID: PMC7868323 DOI: 10.3389/fphar.2020.585018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/13/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Prescribing antibiotics to newborns is challenging, as excess antibiotics are a risk factor for increased morbidity and mortality. The objective of this study was to describe the evolution of antibiotic exposure over three years in a large network of level 3 neonatal wards where each center is informed yearly of its own results and the results of other centers and has full autonomy to improve its performance. Patients and Methods: This is a prospective, observational study of antibiotics prescriptions over the 2017–2019 period in a network of 23 French level 3 neonatal wards. The network relied on an internal benchmarking program based on a computerized prescription ordering system. Among others, antibiotics exposure, treatment duration, and antibiotics spectrum index were analyzed. Results: The population consisted of 39,971 neonates (51.5% preterm), 44.3% of which were treated with antibiotics. Of the treated patients, 78.5% started their first antibiotic treatment in the first three days of life. Antibiotic exposure rate significantly declined from 2017 to 2019 (from 46.8% to 42.8%, p < 0.0001); this decline was significant in groups with gestational age >26 weeks, but not in the group with extremely low gestational age <27 weeks. Gentamicin, cefotaxime, amoxicillin (ampicillin), vancomycin, and amikacin were the antibiotics most prescribed. The lower the gestational age, the higher the exposure for cefotaxime, vancomycin, and amikacin. Compared to 2017, cefotaxime exposure in 2019 declined by 12.6%, but the change was only significant in the gestational age group of 32–36 weeks (17.4%) and at term (20.3%). The triple combination of antibiotics in the first three days decreased by 28.8% from 2017 to 2019, and this was significant in each gestational age group. During the study, the delayed ending of antibiotics in unconfirmed early-onset neonatal infection increased from 9.6% to 11.9%. Conclusion: This study showed that a strategy characterized by the collection of information via a computerized order-entry system, analysis of the results by a steering committee representative of all neonatal wards, and complete autonomy of neonatal wards in the choice of prescription modalities, is associated with a significant reduction in the use of antibiotics in newborns with gestational age greater than 26 weeks.
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Affiliation(s)
- Séverine Martin-Mons
- Centre D'Etudes Périnatales de L'Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France.,Société LogipremF, Saint-Pierre, France
| | - Simon Lorrain
- Centre D'Etudes Périnatales de L'Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
| | - Silvia Iacobelli
- Centre D'Etudes Périnatales de L'Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
| | - Béatrice Gouyon
- Centre D'Etudes Périnatales de L'Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France.,Société LogipremF, Saint-Pierre, France
| | - Jean-Bernard Gouyon
- Centre D'Etudes Périnatales de L'Océan Indien (Université de La Réunion), CHU de La Réunion Site Sud, Saint-Pierre, France
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Oshima Y, Tanaka S, Tsumura K, Tsuda S, So K, Shinagawa T, Yamasaki F, Kawaguchi A, Nomiyama M, Yokoyama M. Amniotic fluid Gram stain and interleukin-6 can predict early-onset neonatal sepsis. J Obstet Gynaecol Res 2020; 47:726-733. [PMID: 33314429 DOI: 10.1111/jog.14595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/12/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
AIM To clarify whether amniotic fluid findings (Gram stain and interleukin [IL]-6 level) can predict early-onset neonatal sepsis (EONS) before delivery. METHODS We compared the sensitivity and specificity and the values of the area under the receiver-operating characteristic (AUROC) curve of maternal inflammatory responses and amniotic fluid findings using IL-6 and Gram stain to predict EONS. Patients who underwent amniocentesis for suspected intra-amniotic infection (IAI) after 22 weeks and 0 days of gestation and delivered on the same day at our hospital between January 2013 and December 2018 were included. RESULTS Out of 200 patients, EONS developed in 9 patients. The AUROC curves of maternal white blood cells count, C-reactive protein and body temperature were low (range, 0.6-0.7), whereas that of amniotic fluid IL-6 was high (0.90). Sensitivity and specificity for amniotic fluid findings were, respectively, 100% and 67% for IL-6 (cut-off value: 17.4 ng/mL) and 100% and 88% for the Gram stain; these values were superior to those of maternal inflammatory responses. When examining the accuracy of the amniotic fluid Gram stain separately before and after 34 gestation weeks, similar results were obtained. Amniotic fluid IL-6 before 34 gestation weeks showed specificity similar to that of the Gram stain; however, there were large differences in cut-off values based on gestational age. CONCLUSION Gram stain results of amniotic fluid can predict EONS with high sensitivity and specificity when IAI is suspected. False-negative amniotic fluid Gram stain results can be prevented by measuring amniotic fluid IL-6 simultaneously.
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Affiliation(s)
- Yuko Oshima
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Satoko Tanaka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
| | - Keisuke Tsumura
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Satoko Tsuda
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Kunio So
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Takaaki Shinagawa
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Fumio Yamasaki
- Department of Pathology, Japan Community Health Care Organization, Saga Central Hospital, Saga, Japan
| | - Atsushi Kawaguchi
- Center for Comprehensive Community Medicine Faculty of Medicine, Saga University, Saga, Japan
| | - Makoto Nomiyama
- Department of Obstetrics and Gynecology, National Hospital Organization, Saga National Hospital, Saga, Japan
| | - Masatoshi Yokoyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saga University, Saga, Japan
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Abstract
Antibiotics are administered to the vast majority of preterm newborns and to a substantial proportion of term infants in the hours after birth due to risk for early-onset sepsis. The approaches taken to determine which newborns should be evaluated for early-onset sepsis, and what type and duration of antibiotics are administered, are important elements of neonatal antibiotic stewardship. The use of multivariate prediction models for sepsis risk assessment among infants born ≥35 weeks' gestation can safely reduce the use of empiric antibiotic therapy. Approaches incorporating serial physical examination may also contribute to decreasing empiric antibiotic exposure among such infants. Among infants born <35 weeks' gestation, delivery characteristics can be used to identify preterm infants at low enough risk of early infection that empiric therapies are not required. Data informing the epidemiology, microbiology and antibiotic susceptibility patterns of early-onset sepsis pathogens can be used to optimize antibiotic choice for empiric and targeted antibiotic therapy to ensure that effective therapies are administered, while decreasing the risks associated with broad-spectrum antibiotic exposure. Optimal use of blood culture and time to positivity data can also contribute to decreasing the risks associated with prolonged antibiotic administration in the face of sterile cultures.
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Affiliation(s)
- Michael W Kuzniewicz
- Perinatal Research Unit, Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States; Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States
| | - Karen M Puopolo
- Division of Neonatology and Center for Pediatric Clinical Excellence, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, United States; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
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43
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Cantey JB. Early Antibiotic Therapy and Adverse Outcomes in Preterm Infants: Time for a Trial! J Pediatr 2020; 227:13-14. [PMID: 32693104 DOI: 10.1016/j.jpeds.2020.07.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/15/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, University of Texas Health San Antonio, San Antonio, Texas.
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Meyers JM, Tulloch J, Brown K, Caserta MT, D'Angio CT. A Quality Improvement Initiative To Optimize Antibiotic Use in a Level 4 NICU. Pediatrics 2020; 146:peds.2019-3956. [PMID: 33055227 DOI: 10.1542/peds.2019-3956] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Given the risks associated with antibiotics, efforts to reduce unnecessary antibiotic use in the NICU have become increasingly urgent. In 2016, a comprehensive 3-year quality improvement (QI) initiative was conducted in a level 4 NICU that sought to decrease the antibiotic use rate (AUR) by 20%. METHODS This local QI initiative was conducted in the context of a multicenter learning collaborative focused on decreasing unnecessary antibiotic use. Improvement strategies focused on addressing gaps in the core elements of antibiotic stewardship programs. Outcome measures included the AUR and the percent of infants discharged without antibiotic exposure. Process measures included the percent of infants evaluated for early-onset sepsis (EOS) and duration of antibiotics used for various infections. Statistical process control charts were used to display and analyze data over time. RESULTS The AUR decreased from 27.6% at baseline to 15.5%, a 43% reduction, and has been sustained for >18 months. Changes most attributable to this decrease include implementation of the sepsis risk calculator, adopting a 36-hour rule-out period for sepsis evaluations, a 36-hour antibiotic hard stop, and novel guideline for EOS evaluation among infants <35 weeks. The percent of infants discharged without antibiotic exposure increased from 15.8% to 35.1%. The percent of infants ≥36 weeks undergoing evaluation for EOS decreased by 42.3% and for those <35 weeks by 26%. CONCLUSIONS Our efforts significantly reduced antibiotic use and exposure in our NICU. Our comprehensive, rigorous approach to QI is applicable to teams focused on improvement.
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Affiliation(s)
| | | | - Kristen Brown
- Department of Nursing, University of Rochester Medical Center, Rochester, New York
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Challenges in developing a consensus definition of neonatal sepsis. Pediatr Res 2020; 88:14-26. [PMID: 32126571 DOI: 10.1038/s41390-020-0785-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/24/2019] [Accepted: 01/13/2020] [Indexed: 01/03/2023]
Abstract
Sepsis remains a leading cause of morbidity and mortality in the neonatal population, and at present, there is no unified definition of neonatal sepsis. Existing consensus sepsis definitions within paediatrics are not suited for use in the NICU and do not address sepsis in the premature population. Many neonatal research and surveillance networks have criteria for the definition of sepsis within their publications though these vary greatly and there is typically a heavy emphasis on microbiological culture. The concept of organ dysfunction as a diagnostic criterion for sepsis is rarely considered in neonatal literature, and it remains unclear how to most accurately screen neonates for organ dysfunction. Accurately defining and screening for sepsis is important for clinical management, health service design and future research. The progress made by the Sepsis-3 group provides a roadmap of how definitions and screening criteria may be developed. Similar initiatives in neonatology are likely to be more challenging and would need to account for the unique presentation of sepsis in term and premature neonates. The outputs of similar consensus work within neonatology should be twofold: a validated definition of neonatal sepsis and screening criteria to identify at-risk patients earlier in their clinical course. IMPACT: There is currently no consensus definition of neonatal sepsis and the definitions that are currently in use are varied.A consensus definition of neonatal sepsis would benefit clinicians, patients and researchers.Recent progress in adults with publication of Sepsis-3 provides guidance on how a consensus definition and screening criteria for sepsis could be produced in neonatology.We discuss common themes and potential shortcomings in sepsis definitions within neonatology.We highlight the need for a consensus definition of neonatal sepsis and the challenges that this task poses.
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Stoll BJ, Puopolo KM, Hansen NI, Sánchez PJ, Bell EF, Carlo WA, Cotten CM, D’Angio CT, Kazzi SNJ, Poindexter BB, Van Meurs KP, Hale EC, Collins MV, Das A, Baker CJ, Wyckoff MH, Yoder BA, Watterberg KL, Walsh MC, Devaskar U, Laptook AR, Sokol GM, Schrag SJ, Higgins RD. Early-Onset Neonatal Sepsis 2015 to 2017, the Rise of Escherichia coli, and the Need for Novel Prevention Strategies. JAMA Pediatr 2020; 174:e200593. [PMID: 32364598 PMCID: PMC7199167 DOI: 10.1001/jamapediatrics.2020.0593] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Early-onset sepsis (EOS) remains a potentially fatal newborn condition. Ongoing surveillance is critical to optimize prevention and treatment strategies. OBJECTIVE To describe the current incidence, microbiology, morbidity, and mortality of EOS among a cohort of term and preterm infants. DESIGN, SETTING, AND PARTICIPANTS This prospective surveillance study included a cohort of infants born at a gestational age (GA) of at least 22 weeks and birth weight of greater than 400 g from 18 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network from April 1, 2015, to March 31, 2017. Data were analyzed from June 14, 2019, to January 28, 2020. MAIN OUTCOMES AND MEASURES Early-onset sepsis defined by isolation of pathogenic species from blood or cerebrospinal fluid culture within 72 hours of birth and antibiotic treatment for at least 5 days or until death. RESULTS A total of 235 EOS cases (127 male [54.0%]) were identified among 217 480 newborns (1.08 [95% CI, 0.95-1.23] cases per 1000 live births). Incidence varied significantly by GA and was highest among infants with a GA of 22 to 28 weeks (18.47 [95% CI, 14.57-23.38] cases per 1000). No significant differences in EOS incidence were observed by sex, race, or ethnicity. The most frequent pathogens were Escherichia coli (86 [36.6%]) and group B streptococcus (GBS; 71 [30.2%]). E coli disease primarily occurred among preterm infants (68 of 131 [51.9%]); GBS disease primarily occurred among term infants (54 of 104 [51.9%]), with 24 of 45 GBS cases (53.3%) seen in infants born to mothers with negative GBS screening test results. Intrapartum antibiotics were administered to 162 mothers (68.9%; 110 of 131 [84.0%] preterm and 52 of 104 [50.0%] term), most commonly for suspected chorioamnionitis. Neonatal empirical antibiotic treatment most frequently included ampicillin and gentamicin. All GBS isolates were tested, but only 18 of 81 (22.2%) E coli isolates tested were susceptible to ampicillin; 6 of 77 E coli isolates (7.8%) were resistant to both ampicillin and gentamicin. Nearly all newborns with EOS (220 of 235 [93.6%]) displayed signs of illness within 72 hours of birth. Death occurred in 38 of 131 infected infants with GA of less than 37 weeks (29.0%); no term infants died. Compared with earlier surveillance (2006-2009), the rate of E coli infection increased among very low-birth-weight (401-1500 g) infants (8.68 [95% CI, 6.50-11.60] vs 5.07 [95% CI, 3.93-6.53] per 1000 live births; P = .008). CONCLUSIONS AND RELEVANCE In this study, EOS incidence and associated mortality disproportionately occurred in preterm infants. Contemporary cases have demonstrated the limitations of current GBS prevention strategies. The increase in E coli infections among very low-birth-weight infants warrants continued study. Ampicillin and gentamicin remained effective antibiotics in most cases, but ongoing surveillance should monitor antibiotic susceptibilities of EOS pathogens.
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Affiliation(s)
- Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston and Children’s Memorial Hermann Hospital, Houston
| | - Karen M. Puopolo
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Nellie I. Hansen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Pablo J. Sánchez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus
| | | | | | | | - Carl T. D’Angio
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Brenda B. Poindexter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio,Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Krisa P. Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Ellen C. Hale
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Carol J. Baker
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center, Houston and Children’s Memorial Hermann Hospital, Houston
| | - Myra H. Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Bradley A. Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Kristi L. Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Uday Devaskar
- Department of Pediatrics, UCLA (University of California, Los Angeles)
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, Rhode Island
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland,Office of Research, George Mason University College of Health and Human Services, Fairfax, Virginia
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47
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[A multicenter survey of antibiotic use in very and extremely low birth weight infants in Hunan Province]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 32571452 PMCID: PMC7390206 DOI: 10.7499/j.issn.1008-8830.1912085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate the current status of antibiotic use for very and extremely low birth weight (VLBW/ELBW) infants in neonatal intensive care units (NICUs) of Hunan Province. METHODS The use of antibiotics was investigated in multiple level 3 NICUs of Hunan Province for VLBW and ELBW infants born between January, 2017 and December, 2017. RESULTS The clinical data of 1 442 VLBW/ELBW infants were collected from 24 NICUs in 2017. The median antibiotic use duration was 17 days (range: 0-86 days), accounting for 53.0% of the total length of hospital stay. The highest duration of antibiotic use was up to 91.4% of the total length of hospital stay, with the lowest at 14.6%. In 16 out of 24 NICUs, the antibiotic use duration was accounted for more than 50.0% of the hospitalization days. There were 113 cases with positive bacterial culture grown in blood or cerebrospinal fluid, making the positive rate of overall bacterial culture as 7.84%. The positive rate of bacterial culture in different NICUs was significantly different from 0% to 14.9%. The common isolated bacterial pathogens Klebsiella pneumoniae was 29 cases (25.7%); Escherichia coli 12 cases (10.6%); Staphylococcus aureus 3 cases (2.7%). The most commonly used antibiotics were third-generation of cephalosporins, accounting for 41.00% of the total antibiotics, followed by penicillins, accounting for 32.10%, and followed by carbapenems, accounting for 13.15%. The proportion of antibiotic use time was negatively correlated with birth weight Z-score and the change in weight Z-score between birth and hospital discharge (rs=-0.095, -0.151 respectively, P<0.01), positively correlated with death/withdrawal of care (rs=0.196, P<0.01). CONCLUSIONS Antibiotics used for VLBW/ELBW infants in NICUs of Hunan Province are obviously prolonged in many NICUs. The proportion of routine use of third-generation of cephalosporins and carbapenems antibiotics is high among the NICUs.
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Villamor-Martinez E, Lubach GA, Rahim OM, Degraeuwe P, Zimmermann LJ, Kramer BW, Villamor E. Association of Histological and Clinical Chorioamnionitis With Neonatal Sepsis Among Preterm Infants: A Systematic Review, Meta-Analysis, and Meta-Regression. Front Immunol 2020; 11:972. [PMID: 32582153 PMCID: PMC7289970 DOI: 10.3389/fimmu.2020.00972] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/24/2020] [Indexed: 12/13/2022] Open
Abstract
Chorioamnionitis (CA) is considered a key risk factor for very preterm birth and for developing early onset sepsis (EOS) in preterm infants, but recent data suggest that CA might be protective against late onset sepsis (LOS). We performed a systematic review and meta-analysis of studies exploring the association between CA and sepsis. A comprehensive literature search was performed in PubMed/MEDLINE and EMBASE, from their inception to December 1, 2018. A random-effects model was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Sources of heterogeneity were analyzed by subgroup and meta-regression analyses. The following categories of sepsis were analyzed: EOS, LOS, unspecified onset sepsis (UOS), culture-proven, and clinical sepsis. CA was subdivided into clinical and histological chorioamnionitis. Funisitis was also analyzed. We found 3,768 potentially relevant studies, of which 107 met the inclusion criteria (387,321 infants; 44,414 cases of CA). Meta-analysis showed an association between any CA and any EOS (OR 4.29, CI 3.63-5.06), any LOS (OR 1.29, CI 1.11-1.54), and any UOS (OR 1.59, CI 1.11-1.54). Subgroup analysis showed that CA was associated with culture-proven EOS (OR 4.69, CI 3.91-5.56), clinical EOS (OR 3.58, CI 1.90-6.76), and culture-proven LOS (OR 1.31, CI 1.12-1.53), but not with clinical LOS (OR 1.52, CI 0.78-2.96). The presence of funisitis did not increase the risk of either EOS or LOS when compared with CA without funisitis. CA-exposed infants had lower gestational age (-1.11 weeks, CI -1.37 to -0.84) than the infants not exposed to CA. Meta-regression analysis showed that the lower gestational age of the CA group correlated with the association between CA and LOS but not with the association between CA and EOS. In conclusion, our data suggest that the positive association between chorioamnionitis and LOS may be modulated by the effect of chorioamnionitis on gestational age.
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Affiliation(s)
- Eduardo Villamor-Martinez
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - George A Lubach
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - Owais Mohammed Rahim
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - Pieter Degraeuwe
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - Luc J Zimmermann
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - Boris W Kramer
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
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49
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Mukhopadhyay S, Puopolo KM, Hansen NI, Lorch SA, DeMauro SB, Greenberg RG, Cotten CM, Sánchez PJ, Bell EF, Eichenwald EC, Stoll BJ. Impact of Early-Onset Sepsis and Antibiotic Use on Death or Survival with Neurodevelopmental Impairment at 2 Years of Age among Extremely Preterm Infants. J Pediatr 2020; 221:39-46.e5. [PMID: 32446491 PMCID: PMC7248124 DOI: 10.1016/j.jpeds.2020.02.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/05/2020] [Accepted: 02/17/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the hypothesis that early-onset sepsis increases risk of death or neurodevelopmental impairment (NDI) among preterm infants; and that among infants without early-onset sepsis, prolonged early antibiotics alters risk of death/NDI. STUDY DESIGN Retrospective cohort study of infants born at the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers (2006-2014) at 22-26 weeks of gestation and birth weight 401-1000 g. Early-onset sepsis defined as growth of a pathogen from blood or cerebrospinal fluid culture ≤72 hours after birth. Prolonged early antibiotics was defined as antibiotics initiated ≤72 hours and continued ≥5 days without culture-confirmed infection, necrotizing enterocolitis, or spontaneous perforation. Primary outcome was death before follow-up or NDI assessed at 18-26 months corrected age. Poisson regression was used to estimate adjusted relative risk (aRR) and CI for early-onset sepsis outcomes. A propensity score for receiving prolonged antibiotics was derived from early clinical factors and used to match infants (1:1) with and without prolonged antibiotic exposure. Log binomial models were used to estimate aRR for outcomes in matched infants. RESULTS Among 6565 infants, those with early-onset sepsis had higher aRR (95% CI) for death/NDI compared with infants managed with prolonged antibiotics (1.18 [1.06-1.32]) and to infants without prolonged antibiotics (1.23 [1.10-1.37]). Propensity score matching was achieved for 4362 infants. No significant difference in death/NDI (1.04 [0.98-1.11]) was observed with or without prolonged antibiotics among the matched cohort. CONCLUSIONS Early-onset sepsis was associated with increased risk of death/NDI among extremely preterm infants. Among matched infants without culture-confirmed infection, prolonged early antibiotic administration was not associated with death/NDI.
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Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Scott A. Lorch
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sara B. DeMauro
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | - Pablo J. Sánchez
- Neonatology and Pediatric Infectious Diseases, Nationwide Children’s Hospital, The Ohio State University College of Medicine, The Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Eric C. Eichenwald
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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50
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Flannery DD, Mukhopadhyay S, Jensen EA, Gerber JS, Passarella MR, Dysart K, Aghai ZH, Greenspan J, Puopolo KM. Influence of Patient Characteristics on Antibiotic Use Rates Among Preterm Infants. J Pediatric Infect Dis Soc 2020; 10:97-103. [PMID: 32170951 PMCID: PMC7996645 DOI: 10.1093/jpids/piaa022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The antibiotic use rate (AUR) has emerged as a potential metric for neonatal antibiotic use, but reported center-level AURs are limited by differences in case mix. The objective of this study was to identify patient characteristics associated with AUR among a large cohort of preterm infants. METHODS Retrospective observational study using the Optum Neonatal Database, including infants born from January 1, 2010 through November 30, 2016 with gestational age 23-34 weeks admitted to neonatal units across the United States. Exposures were patient-level characteristics including length of stay, gestational age, sex, race/ethnicity, bacterial sepsis, necrotizing enterocolitis, and survival status. The primary outcome was AUR, defined as days with ≥ 1 systemic antibiotic administered divided by length of stay. Descriptive statistics, univariable comparative analyses, and generalized linear models were utilized. RESULTS Of 17 910 eligible infants, 17 836 infants (99.6%) from 1090 centers were included. Median gestation was 32.9 (interquartile range [IQR], 30.3-34) weeks. Median length of stay was 25 (IQR, 15-46) days and varied by gestation. Overall median AUR was 0.13 (IQR, 0-0.26) and decreased over time. Gestational age, sex, and race/ethnicity were independently associated with AUR (P < .01). AUR and gestational age had an unexpected inverse parabolic relationship, which persisted when only surviving infants without bacterial sepsis or necrotizing enterocolitis were analyzed. CONCLUSIONS Neonatal AURs are influenced by patient-level characteristics besides infection and survival status, including gestational age, sex, and race/ethnicity. Neonatal antibiotic use metrics that account for patient-level characteristics as well as morbidity case mix may allow for more accurate comparisons and better inform neonatal antibiotic stewardship efforts.
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Affiliation(s)
- Dustin D Flannery
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA,Corresponding Author: Dustin D. Flannery, DO, Children’s Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107. E-mail:
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Molly R Passarella
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Dysart
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jay Greenspan
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karen M Puopolo
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
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