Analysis of Antibiotic Exposure and Early-Onset Neonatal Sepsis in Europe, North America, and Australia

IMPORTANCE

Appropriate use of antibiotics is life-saving in neonatal early-onset sepsis (EOS), but overuse of antibiotics is associated with antimicrobial resistance and long-term adverse outcomes. Large international studies quantifying early-life antibiotic exposure along with EOS incidence are needed to provide a basis for future interventions aimed at safely reducing neonatal antibiotic exposure.

OBJECTIVE

To compare early postnatal exposure to antibiotics, incidence of EOS, and mortality among different networks in high-income countries.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective, cross-sectional study of late-preterm and full-term neonates born between January 1, 2014, and December 31, 2018, in 13 hospital-based or population-based networks from 11 countries in Europe and North America and Australia. The study included all infants born alive at a gestational age greater than or equal to 34 weeks in the participating networks. Data were analyzed from October 2021 to March 2022.

EXPOSURES

Exposure to antibiotics started in the first postnatal week.

MAIN OUTCOMES AND MEASURES

The main outcomes were the proportion of late-preterm and full-term neonates receiving intravenous antibiotics, the duration of antibiotic treatment, the incidence of culture-proven EOS, and all-cause and EOS-associated mortality.

RESULTS

A total of 757 979 late-preterm and full-term neonates were born in the participating networks during the study period; 21 703 neonates (2.86%; 95% CI, 2.83%-2.90%), including 12 886 boys (59.4%) with a median (IQR) gestational age of 39 (36-40) weeks and median (IQR) birth weight of 3250 (2750-3750) g, received intravenous antibiotics during the first postnatal week. The proportion of neonates started on antibiotics ranged from 1.18% to 12.45% among networks. The median (IQR) duration of treatment was 9 (7-14) days for neonates with EOS and 4 (3-6) days for those without EOS. This led to an antibiotic exposure of 135 days per 1000 live births (range across networks, 54-491 days per 1000 live births). The incidence of EOS was 0.49 cases per 1000 live births (range, 0.18-1.45 cases per 1000 live births). EOS-associated mortality was 3.20% (12 of 375 neonates; range, 0.00%-12.00%). For each case of EOS, 58 neonates were started on antibiotics and 273 antibiotic days were administered.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that antibiotic exposure during the first postnatal week is disproportionate compared with the burden of EOS and that there are wide (up to 9-fold) variations internationally. This study defined a set of indicators reporting on both dimensions to facilitate benchmarking and future interventions aimed at safely reducing antibiotic exposure in early life.

Methodologic attributes of quality improvement studies in neonatology: a systematic survey

Introduction

Quality improvement (QI) is a growing field of inquiry in healthcare, including neonatology. However, there is limited information on the study setting, and the methodologic approaches used to develop, implement and evaluate QI interventions in neonatology studies. In this study, we describe these intervention characteristics and approaches.

Methods

Articles were taken from a previous publication. There, we searched MEDLINE for publications of QI studies from 2016 to 16 April 2020. We retrieved all relevant full-text publications and sampled 100 of these articles for data abstraction, stratified by the year of publication. For each QI study, we described several methodological characteristics that included: the clinical topic of QI, setting, whether the study was multicentre, stakeholder engagement, root cause analysis and related problem identification methods, implementation techniques for QI interventions, types of outcomes and statistical analysis methods used.

Results

We assessed 100 studies; most were conducted in the USA (56%). Academic settings and multicentre settings comprised 44% and 24% of studies, respectively. Most studies reported stakeholder engagement (81%), but infrequently reported engagement with leadership (32%) and caregivers (10%). Frequently used techniques for implementing interventions include provider education (82%), formal QI methods (42%) and audit, feedback and benchmarking (40%). Both patient-important clinical outcomes (78%) and process outcomes (89%) were frequently reported. P values were frequently reported (80%), but other statistical techniques were infrequently used.

Conclusion

QI studies in neonatology use diverse multicomponent interventions. Reporting of these methodologic details can be useful in designing, implementing and evaluating QI studies in clinical practice.

130 Adaptation of IHI Joy-in-Work framework to reduce burnout among postgraduate trainees

Primary Subject area

Physician Wellness

Background

Physician burnout is a psychological phenomenon with serious and pervasive consequences on physicians’ mental health, patient safety, and quality of care. Burnout is multifactorial, originating from systemic issues, organizational culture and individual coping skills. Burnout is more common in residency training. Residents experience burnout more intensely due to lack of autonomy, self-efficacy and exposure to mistreatment. Residents are also frontline workers and the future healthcare givers. Organization-led interventions mostly focus on building resilience and mindfulness without addressing systems-level issues.

In our study, we attempted to shift the paradigm to address system-level concerns first. We aimed to adapt Joy-in-Work: a quality improvement framework developed by the Institute for Healthcare Improvement (IHI). This program allows residents to identify system problems that are meaningful to them and empower them to work as a team, taking back their autonomy and self-efficacy.

Objectives

To demonstrate that Joy-in-Work can be adapted effectively into a residency training program to reduce burnout and improve psychological safety among residents.

Design/Methods

The four steps of Joy-in-Work were implemented for residents in a level 3 neonatal intensive care unit. Residents engaged in “what matters” conversations through survey and group meetings, and identified impediments to Joy-in-Work. By applying QI methodology, residents identified priority interventions to eliminate impediments. Finally, the effectiveness of interventions was evaluated. Primary outcomes included prevalence of burnout and psychological safety; secondary outcomes assessed control over workload, and organizational culture. An IHI 12-item questionnaire was administered at baseline and after the interventions. To assess sustainability, a survey was also conducted one year after the implementation. We assessed adherence to interventions, nurse practitioners’ satisfaction and residents’ workload indicators.

Results

Through the implementation of Joy-in-Work, residents identified autonomy and work life integration as priorities. Stakeholders developed two interventions: change call schedule according to residents’ preferences and earlier afternoon handover time. Burnout was 77.8%, 50% and 75% for three survey periods respectively. Psychological safety increased consistently from 16.7% to 37.5% to 43.8%. Lack of control over workload dropped sharply from 72.2% to 12.5%, with a rebound to 56.3%. Most secondary outcomes demonstrated a similar pattern of positive change initially with reversion to baseline.

Conclusion

We demonstrated that Joy-in-Work is successfully adaptable into a residency setting. Implementation through residents’ engagement and empowerment can decrease burnout and improve psychological safety significantly. The process itself was likely the key driver for achieving positive outcomes rather than the actual interventions. Sustainability remains a key issue that requires systems support.

1199. Provider Perspectives on Nonsterile Glove Use in the NICU

Background

Late-onset infection is a serious cause of mortality and long-term morbidity in NICU patients. Healthcare worker hands are the most common vehicle for transmission of pathogenic organisms to neonates. Studies have suggested a reduction in infections in neonatal and pediatric patients cared for with universal nonsterile glove use.

Methods

We developed an online survey (https://fhspeds.mcmaster.ca/pedsCapOne/surveys/?s=9RDX7EHT79) for clinicians to understand the current glove use and hand hygiene practices in NICUs in North America. The survey was sent to neonatologists and Pediatric Infectious Disease Specialists via the AAP Neonatal-Perinatal Section listserv, SHEA and the Canadian Neonatal Network.

Results

Of 336 responses; the majority were from physicians at level 3 to 4 NICUs (97%), and from the United States (96.1%). Beyond sterile procedures, sterile gloves were used for central line dressing changes (88.4%), contact with central nervous system shunts (61.0%), and direct contact with central lines (57.4%). Nonsterile gloves were used most commonly for universal precautions and diaper changes (Table 1). Almost half of participants also used nonsterile gloves for all patients and 37.5% for extremely low birth weight (<1000 g) infants. While most sites (76.8%) stated that nonsterile gloves were not required for parents, 15.8% requested gloves also for parents. 58% of respondents felt there was not enough evidence for a practice change at this time and 53.3% felt further study was needed to assess the effect of nonsterile gloves and infection (Figures 2 and 3). Almost a third of respondents (n = 109) would be interested in participating in a randomized study to assess glove-based care. Major concerns with this approach included a possible reduction in hand hygiene compliance, environmental waste, and glove contamination (Figure 4).

Conclusion

There is variability in gloving practices across NICUs in North America, with equipoise and interest in a potential randomized study to further explore the hypothesis that nonsterile gloves prevent late-onset infections in neonates.

Disclosures

All authors: No reported disclosures.

1200. Parent Perspectives on Infection Prevention and Control in the NICU

Background

Infants admitted to the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections (HAIs) due to their immature immune systems and need for invasive devices. Parents have frequent contact with their infants and present an opportunity for prevention practices. The objective of this study was to evaluate parental opinions related to infection prevention and control (IPAC) in the NICU.

Methods

An online survey was sent to a network of 2,000 parents from the Canadian Premature Babies Foundation. The survey included questions about patient-centered outcomes, IPAC practices experienced during their infants’ NICU admission, and specifically, opinions regarding nonsterile glove use by both healthcare workers (HCWs) and parents.

Results

A total of 72 parents responded to the survey. The majority were parents of infants born at less than 37 weeks (94%) and had been admitted to an NICU after 2010 (89%). When asked about preventing infections in the NICU, 82% of parents indicated they had been given information on how the NICU prevents infection and 96% had been told how they can prevent infection in their infant (Table 1). The most common information was related to hand hygiene (96%) and what to do if they were unwell (89%). Opportunities for improvement included being bare below the elbow, nail care, and feeding human milk. With respect to IPAC outcomes of interest, 96% agreed that it was important to study interventions to reduce bloodstream infections (BSIs). Other outcomes of interest (Table 2) included necrotizing enterocolitis (72%), antibiotic-resistant organism acquisition (69%), and length of stay (67%). With respect to glove use, 89% of parents felt that it was acceptable for HCWs to wear gloves when caring for their infant. Only 37% of parents indicated that they would want to wear gloves if HCWs were wearing gloves, but 47% would consider wearing gloves if there was evidence that it reduced infection in their infant.

Conclusion

Reducing infections, specifically BSIs, in infants admitted to the NICU is an outcome of interest for parents. Nonsterile gloving by HCWs is considered an acceptable strategy by parents to reduce infections. Missed opportunities exist for the education of parents in the NICU on IPAC practices.

Disclosures

All authors: No reported disclosures.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

OBJECTIVE

To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort.

STUDY DESIGN

Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI.

RESULTS

The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late-onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied.

CONCLUSIONS

The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

OBJECTIVE

To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs).

STUDY DESIGN

Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity.

RESULTS

Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3).

CONCLUSIONS

The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Self-disinfecting sink drains reduce the Pseudomonas aeruginosa bioburden in a neonatal intensive care unit

AIM

Water in sink drains is a known source of gram-negative bacteria. We aimed to evaluate the impact of self-disinfecting sink drains on the emission of aerosolised bacteria and on Pseudomonas aeruginosa acquisition among neonates.

METHODS

Aerosol bacterial growth and patient Pseudomonas aeruginosa acquisition rates were measured at baseline (Phase One), for 13 months after sinks were relocated or redesigned during refurbishment (Phase Two) and for 13 months after introducing self-disinfecting sink drains (Phase Three).

RESULTS

Cultures were positive for bacterial growth in 56%, 24% and 13% of the tested aerosols in Phases One, Two and Three, respectively. Comparing Phases Two and Three produced an odds ratio (OR) of 0.47, with a 95% confidence interval (CI) of 0.22-0.99 (p = 0.047), for all bacteria and an OR of 0.31 and CI of 0.12-0.79 (p = 0.013) for Pseudomonas aeruginosa. Rates of Pseudomonas aeruginosa positive clinical cultures were 0.34, 0.27 and 0.13 per 1000 patient days during the respective phases, with a significant increase of time to the next positive clinical culture in Phase Three.

CONCLUSION

Self-disinfecting sink drains were superior to sink replacements in preventing emissions from aerosols pathogens and may reduce hospital-acquired infections. The bioburden reduction should be confirmed in a larger multicentre trial.