Prospective surveillance of antibiotic use in the neonatal intensive care unit: results from the SCOUT study

Impacts of Multidrug-Resistant Pathogens and Inappropriate Initial Antibiotic Therapy on the Outcomes of Neonates with Ventilator-Associated Pneumonia

It is unknown whether neonatal ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) pathogens and inappropriate initial antibiotic treatment is associated with poor outcomes after adjusting for confounders. Methods: We prospectively observed all neonates with a definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and March 2020. All clinical features, therapeutic interventions, and outcomes were compared between the MDR–VAP and non-MDR–VAP groups. Multivariate regression analyses were used to investigate independent risk factors for treatment failure. Results: Of 720 neonates who were intubated for more than 2 days, 184 had a total of 245 VAP episodes. The incidence rate of neonatal VAP was 10.1 episodes/per 1000 ventilator days. Ninety-six cases (39.2%) were caused by MDR pathogens. Neonates with MDR–VAP were more likely to receive inadequate initial antibiotic therapy (51.0% versus 4.7%; p < 0.001) and had delayed resolution of clinical symptoms (38.5% versus 25.5%; p = 0.034), although final treatment outcomes were comparable with the non-MDR–VAP group. Inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. The VAP-attributable mortality rate and overall mortality rate of this cohort were 3.7% and 12.0%, respectively. Independent risk factors for treatment failure included presence of concurrent bacteremia (OR 4.83; 95% CI 2.03–11.51; p < 0.001), septic shock (OR 3.06; 95% CI 1.07–8.72; p = 0.037), neonates on high-frequency oscillatory ventilator (OR 4.10; 95% CI 1.70–9.88; p = 0.002), and underlying neurological sequelae (OR 3.35; 95% CI 1.47–7.67; p = 0.004). Conclusions: MDR–VAP accounted for 39.2% of all neonatal VAP in the neonatal intensive care unit (NICU), but neither inappropriate initial antibiotics nor MDR pathogens were associated with treatment failure. Neonatal VAP with concurrent bacteremia, septic shock, and underlying neurological sequelae were independently associated with final worse outcomes.

Analysis of antibiotic treatment of children in a Shanghai tertiary hospital based on point prevalence surveys

Background

Misuse and overuse of antibiotics by physicians in the treatment of children is common in China. This study aimed to reveal the overall use of antibiotics to treat children hospitalized in four types of pediatric wards.

Methods

Seven independent point prevalence surveys (PPSs) were conducted in Shanghai Children’s Hospital of Shanghai Jiao Tong University over the period 2012 to 2018. Pediatric ward types were defined general pediatric medical, pediatric surgical, pediatric intensive care units (PICU), and neonatal.

Results

A total of 3975 pediatric patients were included in the study, of which 63.9% received at least one dose antibiotic. The top five classes of antibiotics administered were cephalosporins (43.8%, n = 1743), penicillins (13.2%, n = 526), carbapenems (8.7%, n = 347), nitroimidazoles (7.1%, n = 281) and macrolides (6.5%, n = 257). The five most commonly used generic antibiotics were cefuroxime (14.9%, n = 594), ceftriaxone (9.7%, n = 387), cefotaxime (9.0%, n = 358), meropenem (8.1%, n = 320) and ampicillin/sulbactam (6.0%, n = 239). Meropenem was among top five antibiotics prescribed in the general pediatric, PICU and neonatal wards and sixth in the pediatric surgical wards. Of all children on antibiotics, 23.4% received prophylactic treatment, and prophylaxis accounted for 68.1% of indications for treatment in the pediatric surgical wards.

Conclusions

Given that over-treatment with third-generation cephalosporins and carbapenems has been associated with treatment-resistant infections, the prescription of these drugs should be strictly controlled and monitored, and measures should be taken to improve the management of surgical prophylaxis in hospitalized children in China.

Understanding the impact of antibiotic perturbation on the human microbiome

The human gut microbiome is a dynamic collection of bacteria, archaea, fungi, and viruses that performs essential functions for immune development, pathogen colonization resistance, and food metabolism. Perturbation of the gut microbiome's ecological balance, commonly by antibiotics, can cause and exacerbate diseases. To predict and successfully rescue such perturbations, first, we must understand the underlying taxonomic and functional dynamics of the microbiome as it changes throughout infancy, childhood, and adulthood. We offer an overview of the healthy gut bacterial architecture over these life stages and comment on vulnerability to short and long courses of antibiotics. Second, the resilience of the microbiome after antibiotic perturbation depends on key characteristics, such as the nature, timing, duration, and spectrum of a course of antibiotics, as well as microbiome modulatory factors such as age, travel, underlying illness, antibiotic resistance pattern, and diet. In this review, we discuss acute and chronic antibiotic perturbations to the microbiome and resistome in the context of microbiome stability and dynamics. We specifically discuss key taxonomic and resistance gene changes that accompany antibiotic treatment of neonates, children, and adults. Restoration of a healthy gut microbial ecosystem after routine antibiotics will require rationally managed exposure to specific antibiotics and microbes. To that end, we review the use of fecal microbiota transplantation and probiotics to direct recolonization of the gut ecosystem. We conclude with our perspectives on how best to assess, predict, and aid recovery of the microbiome after antibiotic perturbation.

Review of Drug Utilization Studies in Neonatal Units: A Global Perspective

Rational prescribing is challenging in neonatology. Drug utilization studies help identify and define the problem. We performed a review of the literature on drug use in neonatal units and describe global variations. We searched databases (EMBASE, CINAHL and Medline) from inception to July 2020, screened studies and extracted relevant data (two reviewers). The search revealed 573 studies of which 84 were included. India (n = 14) and the USA (n = 13) reported the most. Data collection was prospective (n = 56) and retrospective (n = 26), mostly (n = 52) from one center only. Sixty studies described general drug use in 34 to 450,386 infants (median (IQR) 190 (91-767)) over a median (IQR) of 6 (3-18) months. Of the participants, 20-87% were preterm. The mean number of drugs per infant (range 11.1 to 1.7, pooled mean (SD) 4 (2.4)) was high with some reporting very high burden (≥30 drugs per infant in 8 studies). This was not associated with the proportion of preterm infants included. Antibiotics were the most frequently used drug. Drug use patterns were generally uniform with some variation in antibiotic use and more use of phenobarbitone in Asia. This study provides a global perspective on drug utilization in neonates and highlights the need for better quality information to assess rational prescribing.

Reducing Vancomycin Use in a Level IV NICU

BACKGROUND AND OBJECTIVES

Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year.

METHODS

In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program.

RESULTS

We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days.

CONCLUSIONS

Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Time to Positivity of Neonatal Blood Cultures for Early-onset Sepsis

BACKGROUND

In newborns at risk for early-onset sepsis, empiric antibiotics are often initiated while awaiting the results of blood cultures. The duration of empiric therapy can be guided by the time to positivity (TTP) of blood cultures. The objective of the study was to determine the TTP of neonatal blood cultures for early-onset sepsis and the factors which may impact TTP.

METHODS

Observational study of blood cultures growing pathogenic species obtained within 72 hours of birth from infants born at 23-42 weeks gestation, at 19 hospitals in Northern California, Boston, and Philadelphia. TTP was defined as the time from blood culture collection to the time organism growth was reported by the microbiology laboratory.

RESULTS

A total of 594 blood cultures growing pathogenic bacteria were identified. Group B Streptococcus and Escherichia coli accounted for 74% of blood culture isolates. Median TTP was 21.0 hours (interquartile range, 17.1-25.3 hours). Blood cultures were identified as positive by 24 hours after they were obtained in 68% of cases; by 36 hours in 94% of cases; and by 48 hours in 97% of cases. Neither the administration of maternal intrapartum antibiotic prophylaxis, gestational age <35 weeks, nor blood culture system impacted median TTP.

CONCLUSIONS

Pathogens are isolated by 36 hours after blood culture collection in 94% of neonatal early blood cultures, regardless of maternal antibiotic administration. TTP information can inform decisions regarding the duration of empiric neonatal antibiotic therapies.

Impact of Early-Onset Sepsis and Antibiotic Use on Death or Survival with Neurodevelopmental Impairment at 2 Years of Age among Extremely Preterm Infants

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.

Using NHSN's Antimicrobial Use Option to Monitor and Improve Antibiotic Stewardship in Neonates

BACKGROUND

The Antimicrobial Use (AU) Option of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) is a surveillance resource that can provide actionable data for antibiotic stewardship programs. Such data are used to enable measurements of AU across hospitals and before, during, and after stewardship interventions.

METHODS

We used monthly AU data and annual facility survey data submitted to the NHSN to describe hospitals and neonatal patient care locations reporting to the AU Option in 2017, examine frequencies of most commonly reported agents, and analyze variability in AU rates across hospitals and levels of care. We used results from these analyses in a collaborative project with Vermont Oxford Network to develop neonatal-specific Standardized Antimicrobial Administration Ratio (SAAR) agent categories and neonatal-specific NHSN Annual Hospital Survey questions.

RESULTS

As of April 1, 2018, 351 US hospitals had submitted data to the AU Option from at least 1 neonatal unit. In 2017, ampicillin and gentamicin were the most frequently reported antimicrobial agents. On average, total rates of AU were highest in level III NICUs, followed by special care nurseries, level II-III NICUs, and well newborn nurseries. Seven antimicrobial categories for neonatal SAARs were created, and 6 annual hospital survey questions were developed.

CONCLUSIONS

A small but growing percentage of US hospitals have submitted AU data from neonatal patient care locations to NHSN, enabling the use of AU data aggregated by NHSN as benchmarks for neonatal antimicrobial stewardship programs and further development of the SAAR summary measure for neonatal AU.

Phase 2 Study of the Safety, Pharmacokinetics and Efficacy of Ceftaroline Fosamil in Neonates and Very Young Infants With Late-onset Sepsis

BACKGROUND

With increasing antimicrobial resistance, antibiotic treatment options for neonatal late-onset sepsis (LOS) are becoming limited. Primary objective of this study was assessment of the safety of ceftaroline fosamil in LOS.

METHODS

Eligible neonates and very young infants 7 to <60 days of age with LOS were enrolled in this phase 2, open-label, multicenter study (NCT02424734) and received ceftaroline fosamil 4 or 6 mg/kg every 8 hours by 1-hour intravenous infusion plus intravenous ampicillin and optional aminoglycoside for 48 hours-14 days. Safety was assessed through the final study visit (21-35 days after the last study therapy dose). Efficacy, assessed as clinical and microbiologic response, was evaluated at end-of-treatment and test-of-cure. Pharmacokinetic samples were collected via sparse-sampling protocol.

RESULTS

Eleven patients [54.5% male, median (range) age 24 (12-53) days] were enrolled and received ceftaroline fosamil for a median (range) duration of 8 (3-15) days. Ten adverse events (AEs) occurred in 5 (45.5%) patients (safety population); most frequent AE was diarrhea (n = 2). All except 1 AE (diarrhea) were nontreatment-related. Predominant baseline pathogen was Escherichia coli. No patients were clinical failures at end-of-treatment/test-of-cure. Observed sparse steady-state pharmacokinetics data (19 samples) were comparable to previous pediatric data and generally within 90% model prediction intervals; neonatal probability of target attainment was >95% based on established pharmacokinetic/pharmacodynamic targets.

CONCLUSIONS

Safety in neonates and very young infants was consistent with the known ceftaroline fosamil safety profile. These results support the use of ceftaroline fosamil (6 mg/kg every 8 hours) as a potential treatment option for LOS.

Risk Factors of Initial Inappropriate Antibiotic Therapy and the Impacts on Outcomes of Neonates with Gram-Negative Bacteremia

BACKGROUND

Timely appropriate empirical antibiotic plays an important role in critically ill patients with gram-negative bacteremia. However, the relevant data and significant impacts have not been well studied in the neonatal intensive care unit (NICU).

METHODS

An 8-year (1 January 2007-31 December 2014) cohort study of all NICU patients with gram-negative bacteremia (GNB) in a tertiary-care medical center was performed. Inadequate empirical antibiotic therapy was defined when a patient did not receive any antimicrobial agent to which the causative microorganisms were susceptible within 24 h of blood culture sampling. Neonates with GNB treated with inadequate antibiotics were compared with those who received initial adequate antibiotics.

RESULTS

Among 376 episodes of Gram-negative bacteremia, 75 (19.9%) received inadequate empirical antibiotic therapy. The cause of inadequate treatment was mostly due to the pathogen resistance to prescribed antibiotics (88.0%). Bacteremia caused by Pseudomonas aeruginosa (Odds ratio [OR]: 20.8, P < 0.001) and extended spectrum β-lactamase (ESBL)-producing bacteria (OR: 18.4, P < 0.001) had the highest risk of inadequate treatment. Previous exposure with third generation cephalosporin was identified as the only independent risk factor (OR: 2.52, 95% CI: 1.18-5.37, P = 0.018). Empirically inadequately treated bacteremias were significantly more likely to have worse outcomes than those with adequate therapy, including a higher risk of major organ damage (20.0% versus 6.6%, P < 0.001) and infectious complications (25.3% versus 9.3%, P < 0.001), and overall mortality (22.7% versus 11.0%, P = 0.013). Conclusions: Inadequate empirical antibiotic therapy occurs in one-fifth of Gram-negative bacteremias in the NICU, and is associated with worse outcomes. Additional prospective studies are needed to elucidate the optimal timing and aggressive antibiotic regimen for neonates who are at risk of antibiotic-resistant Gram-negative bacteremia.

Influence of Patient Characteristics on Antibiotic Use Rates Among Preterm Infants

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.

Nutrients and Microbiota in Lung Diseases of Prematurity: The Placenta-Gut-Lung Triangle

Cardiorespiratory function is not only the foremost determinant of life after premature birth, but also a major factor of long-term outcomes. However, the path from placental disconnection to nutritional autonomy is enduring and challenging for the preterm infant and, at each step, will have profound influences on respiratory physiology and disease. Fluid and energy intake, specific nutrients such as amino-acids, lipids and vitamins, and their ways of administration -parenteral or enteral-have direct implications on lung tissue composition and cellular functions, thus affect lung development and homeostasis and contributing to acute and chronic respiratory disorders. In addition, metabolomic signatures have recently emerged as biomarkers of bronchopulmonary dysplasia and other neonatal diseases, suggesting a profound implication of specific metabolites such as amino-acids, acylcarnitine and fatty acids in lung injury and repair, inflammation and immune modulation. Recent advances have highlighted the profound influence of the microbiome on many short- and long-term outcomes in the preterm infant. Lung and intestinal microbiomes are deeply intricated, and nutrition plays a prominent role in their establishment and regulation. There is an emerging evidence that human milk prevents bronchopulmonary dysplasia in premature infants, potentially through microbiome composition and/or inflammation modulation. Restoring antibiotic therapy-mediated microbiome disruption is another potentially beneficial action of human milk, which can be in part emulated by pre- and probiotics and supplements. This review will explore the many facets of the gut-lung axis and its pathophysiology in acute and chronic respiratory disorders of the prematurely born infant, and explore established and innovative nutritional approaches for prevention and treatment.

Recommendations on the diagnosis and the use of antibiotics for early-onset sepsis in preterm infant: consensus of the expert panel from Hunan Province

Preterm infants are at higher risk of developing early-onset sepsis (EOS). Due to non-specific clinical manifestations and lack of laboratory tests for prompt diagnosis of EOS, inappropriate use of antibiotics is common in preterm infants. Prolonged exposure to antibiotics can lead to antibiotic resistance and significantly increases the risk of mortality and morbidity. Based on the latest progress in the diagnosis and treatment for EOS, both in China and overseas, and considering the current condition in Hunan Province, the expert panel of neonatologists in Hunan have reached this consensus after many discussions. This consensus clarifies the risk factors, proposes the diagnostic criteria, and recommends the antibiotic use strategies for EOS in preterm infants. It is emphasized that blood culture results and clinical manifestations are the main basis for the diagnosis of EOS and the duration of antibiotics use in preterm infants.

Effect of Weekly Antibiotic Round on Antibiotic Use in the Neonatal Intensive Care Unit as Antibiotic Stewardship Strategy

Background: Antibiotics are commonly used in the neonatal intensive care unit (NICU). The objective was to observe the effect of weekly antibiotic round in NICU (WARN) to the antibiotic use in NICU. Methods: A retrospective observational study was performed. Departmental-level diagnosis categories and the parameters of antibiotic usage in NICU for the period of 2016-2017 (Phase 1) and 2018-2019 (Phase 2) were collected. WARN in NICU was started since January 2018. A time series forecasting was used to predict the quarterly antibiotic use in Phase 2, based on data from Phase 1. The actual antibiotic use of each quarter in Phase 2 was compared with the predicted values. Results: Totally 9297 neonates were included (4743 in Phase 1, 4488 in Phase 2). The composition of the disease spectrum between Phase 1 and Phase 2 was not different (P > 0.05). In Phase 1 and Phase 2, the overall antibiotic rate was 94.4 and 74.2%, the average accumulative defined daily dose per month was 199.00 ± 55.77 and 66.80 ± 45.64, the median antibiotic use density per month was 10.31 (9.00-13.27) and 2.48 (1.92-4.66), the median accumulative defined daily dose per case per month was 0.10 (0.09-0.13) and 0.03 (0.02-0.47), the number of patients who received any kind of antibiotic per 1000 hospital days per month was 103.45 (99.30-107.48) and 78.66 (74.62-82.77), rate of culture investigation before antibiotics was 64 to 92%, respectively, and all were better than the predicted values (P < 0.01). Conclusion: The implementation of periodical antibiotic rounds was effective in reducing the antibiotics use in the NICU.

A Prospective Cohort Study of Factors Associated with Empiric Antibiotic De-escalation in Neonates Suspected with Early Onset Sepsis (EOS)

BACKGROUND

Prolonged empiric antibiotic use, resulting from diagnostic uncertainties, in suspected early onset sepsis (EOS) cases constitutes a significant problem. Unnecessary antibiotic use increases the risk of antibiotic resistance. Furthermore, prolonged antibiotic use increases the risk of mortality and morbidity in neonates. Proactive measures including empiric antibiotic de-escalation are crucial to overcome these problems.

METHODS

This was a prospective cohort study conducted in the neonatal intensive care units of two public hospitals in Malaysia. Neonates with a gestational age greater than 34 weeks who were started on empiric antibiotics within 72 h of life were screened. The data were then stratified according to de-escalation and non-de-escalation practices, where de-escalation practice was defined as narrowing down or discontinuation of empiric antibiotic within 72 h of treatment.

RESULTS

A total of 1045 neonates were screened, and 429 were included. The neonates were then divided based on de-escalation (n = 207) and non-de-escalation (n = 222) practices. Neonates under non-de-escalation practices showed significantly longer durations of antibiotic use compared to those under de-escalation practices (p < 0.05), with no difference in treatment outcomes. Five factors were found to be associated with de-escalation of antibiotics. They are cesarean section delivery, exposure to antenatal steroids, nil history of maternal pyrexia, absence of meconium-stained amniotic fluid, and normal C-reactive protein ≤ 0.5 mg/dL (p < 0.05).

CONCLUSIONS

Empiric antibiotic de-escalation appears feasible as a routine form of treatment for EOS in late preterm and term neonates.

Antibiotic regimens for neonatal sepsis - a protocol for a systematic review with meta-analysis

BACKGROUND

Sepsis is a major cause of morbidity and mortality among neonates and infants. Antibiotics are a central part of the first line treatment for sepsis in neonatal intensive care units worldwide. However, the evidence on the clinical effects of the commonly used antibiotic regimens for sepsis in neonates remains scarce. This systematic review aims to assess the efficacy and harms of antibiotic regimens for neonatal sepsis.

METHODS

Electronic searches will be conducted in MEDLINE, Embase, The Cochrane Library, CINAHL, ZETOC and clinical trial registries (clinicaltrials.gov and ISRCTN). We will include randomised controlled trials of different antibiotic regimens for sepsis of neonates and infants. Eligible interventions will be any antibiotic regimen. Two reviewers will independently screen, select, and extract data. The methodological quality of individual studies will be appraised following Cochrane methodology. Primary outcomes will be 'all-cause mortality' and 'serious adverse events'. Secondary outcomes will be 'need for respiratory support', 'need for circulatory support', 'neurodevelopmental impairment', ototoxicity, nephrotoxicity and necrotizing enterocolitis. We plan to perform a meta-analysis with trial sequential analysis.

DISCUSSION

This is the study protocol for a systematic review on the effects of different antibiotic regimens for neonatal sepsis. The results of this systematic review intent to adequately inform stakeholders or health care professionals in the field of neonatal sepsis, and to aid appropriate development of treatment guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO reference number: CRD42019134300.

Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection

OBJECTIVES

To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection.

METHODS

We conducted a cross-sectional study of 326 845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates.

RESULTS

The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure.

CONCLUSIONS

The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

Antibiotic Treatment of Suspected and Confirmed Neonatal Sepsis Within 28 Days of Birth: A Retrospective Analysis

Neonatal sepsis causes significant mortality and morbidity worldwide. Diagnosis is usually confirmed via blood culture results. Blood culture sepsis confirmation can take days and suffer from contamination and false negatives. Empiric therapy with antibiotics is common. This study aims to retrospectively describe and compare treatments of blood culture-confirmed and unconfirmed, but suspected, sepsis within the University of Utah Hospital system. Electronic health records were obtained from 1,248 neonates from January 1, 2006, to December 31, 2017. Sepsis was categorized into early-onset (≤3 days of birth, EOS) and late-onset (>3 and ≤28 days of birth, LOS) and categorized as culture-confirmed sepsis if a pathogen was cultured from the blood and unconfirmed if all blood cultures were negative with no potentially contaminated blood cultures. Of 1,010 neonates in the EOS cohort, 23 (2.3%) were culture-confirmed, most with Escherichia coli (42%). Treatment for unconfirmed EOS lasted an average of 6.1 days with primarily gentamicin and ampicillin while confirmed patients were treated for an average of 12.3 days with increased administration of cefotaxime. Of 311 neonates in the LOS cohort, 62 (20%) were culture-confirmed, most culturing coagulase negative staphylococci (46%). Treatment courses for unconfirmed LOS lasted an average of 7.8 days while confirmed patients were treated for an average of 11.4 days, these patients were primarily treated with vancomycin and gentamicin. The use of cefotaxime for unconfirmed EOS and LOS increased throughout the study period. Cefotaxime administration was associated with an increase in neonatal mortality, even when potential confounding factors were added to the logistic regression model (adjusted odds ratio 2.8, 95%CI [1.21, 6.88], p = 0.02). These results may not be generalized to all hospitals and the use of cefotaxime may be a surrogate for other factors. Given the low rate of blood culture positive diagnosis and the high exposure rate of empiric antibiotics, this patient population might benefit from improved diagnostics with reevaluation of antibiotic use guidelines.

Antibiotic Stewardship in the Neonatal Intensive Care Unit: Effects of an Automatic 48-Hour Antibiotic Stop Order on Antibiotic Use

BACKGROUND

Meeting antibiotic stewardship goals in the neonatal intensive care unit (NICU) is challenging because of the unique nature of newborns and the lack of specificity of clinical signs of sepsis. Antibiotics are commonly continued for 48 hours pending culture results and clinical status. The goal of this study was to examine if the implementation of a 48-hour automatic stop (autostop) order during NICU admissions would decrease antibiotic use at UnityPoint Health-Meriter.

METHODS

An observational double-cohort study was performed in a level 3 NICU. Antibiotic use was evaluated before and after the autostop initiative. The admission order set included 48 hours of ampicillin and gentamicin coverage.

RESULTS

After the autostop initiation, total doses given per patient decreased by 35% and doses per patient-day decreased by 25% (P < .0001). The greatest effect was a 66% decrease in the use of vancomycin, an antibiotic not included in the admission order set. Providers proactively continued antibiotics for infants in whom they had high suspicion for sepsis and in those with positive blood or cerebral spinal fluid culture results.

CONCLUSIONS

An admission-order autostop was highly effective at decreasing antibiotic usage with no doses intended for a pathogen missed. Fewer doses of certain antibiotics outside of the admission order set were administered, particularly vancomycin, which results in our speculation that provider awareness of the antibiotic stewardship initiative might have altered prescribing practices.

The evaluation of the appropriate gentamicin use for preterm infants

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

Effects of immunotherapy on mortality in neonates with suspected or proven sepsis: a systematic review and network meta-analysis

Background

To investigate the efficacies of different immunotherapies in neonates with suspected or proven sepsis.

Methods

We searched the Cochrane Library, EMBASE, MEDLINE, EBSCOhost, and Web of Science for studies published before May 2019 that investigated different immunotherapies in neonates with suspected or proven sepsis. Comparisons were among immunotherapies and between immunotherapy and placebo. The review was registered in the PROSPERO CRD database.

Results

All-cause mortality was not significantly different between patients who received the immunoglobulin (IgG), IgM-enriched immunoglobulin (IgGAM), granulocyte-colony stimulating factor (G-CSF) or granulocyte-macrophage colony stimulating factor (GM-CSF) immunotherapies and those who received placebo. The RRs of the immunotherapies were 0.80 (95% CI: 0.57 to 1.1), 0.45 (95% CI: 0.17 to 1.0), 0.93 (95% CI: 0.64 to 1.2) and 0.67 (95% CI: 0.39 to 1.1), respectively. Compared with placebo, none of the interventions showed statistically significant differences in the duration of hospital stay. The MDs of the immunotherapies were − 2.7 (95% CI: − 8.4 to 3.5), − 0.18 (95% CI: − 7.3 to 7.7), − 1.7 (95% CI: − 7.3 to 3.9) and − 7.2 (95% CI: − 28 to 13), respectively.

Conclusions

No significant differences in all-cause mortality or the duration of hospital stay were found in neonates with suspected or proven sepsis treated with the four types of immunotherapies and those treated with placebo.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1609-1) contains supplementary material, which is available to authorized users.

Audit of Antibiotic Prescribing Practices for Neonatal Sepsis and Measurement of Outcome in New Born Unit at Kenyatta National Hospital

Background

Neonatal sepsis is a leading cause of morbidity and mortality globally. A high index of suspicion is required since features of sepsis are nonspecific. Auditing of antibiotic use is necessary to reduce misuse and minimise development of antibiotic resistance.

Objectives

To assess the antibiotic prescribing practices in NBU at KNH against recommended Kenyan guidelines for neonatal sepsis. In addition, outcome within 7 days was described.

Methods

This was a prospective audit of 320 neonates over a 2-month period at NBU of KNH. Data were collected using a structured questionnaire, stored in MS-EXCEL, and analysed using STATA.

Results

Documentation of perinatal risk factors and clinical features at admission and at the time of change of antibiotics was very poor. The rate of investigations to confirm infection was very low. Blood cultures were done only in 13 (4%) neonates on admission, while complete blood count and C reactive protein were done in 224 (70%) and 198 (62%), respectively. Appropriate antibiotics as per the Kenyan guidelines were prescribed in 313 (97.8%) of neonates on admission. However, these were not stopped at 48-72 hours for the 148 (53.62%) who had improved. Overall mortality was high in neonates at 80 (25%). Majority (55%) died within 48 hours. Mortality was high among preterm neonates; 70 (43.8%) died out of 160.

Conclusion

Overall documentation and investigations to confirm infection was poor. The continuation of antibiotics was inappropriate. Overall mortality was high especially in the first 48 hours of admission. To improve documentation, availability of a checklist on admission is recommended.

Challenges and opportunities for antibiotic stewardship among preterm infants

Antibiotic stewardship programmes aim to optimise antimicrobial use to prevent the emergence of resistance species and protect patients from the side effects of unnecessary medication. The high incidence of systemic infection and associated mortality from these infections leads neonatal providers to frequently initiate antibiotic therapy and make empiric antibiotic courses one of the main contributors of antibiotic use in the neonatal units. Yet, premature infants are also at risk for acute life-threatening complications associated with antibiotic use such as necrotising enterocolitis and for long-term morbidities such as asthma. In this review, we discuss specific aspects of antibiotic use in the very low birthweight preterm infants, with a focus on empiric use, that provide opportunities for stewardship practice. We discuss strategies to risk-stratify antibiotic initiation for the risk of early-onset sepsis, optimise empiric therapy duration and antibiotic choice in late-onset sepsis, and standardise decisions for stopping empiric therapy. Lastly, review the evolving role of biomarkers in antibiotic stewardship.

Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study

BACKGROUND

Antimicrobial stewardship programs potentially lead to appropriate antibiotic use, yet the optimal approach for neonates is uncertain. Such a program was implemented in a tertiary care neonatal intensive care unit in October 2012. We evaluated the impact of this program on antimicrobial use and its association with clinical outcomes.

METHODS

In a retrospective cohort study, we examined 1580 neonates who received antimicrobials in the 13-months before and 13-months during program implementation. Prospective audit and feedback was given 5 days a week on each patient who was receiving antibiotic. Pharmacy and microbiology data were linked to clinical data from the local Canadian Neonatal Network database. The primary outcome was days of antibiotic therapy per 1000 patient-days; secondary outcomes included mortality, necrotizing enterocolitis, and antibiotic duration for culture-positive and culture-negative late-onset sepsis. The breadth of antibiotic exposure was compared using the Antibiotic Spectrum Index.

RESULTS

Overall antibiotic use decreased to 339 days of therapy per 1000 patient-days from 395 (14%, P < 0.001), without an increase in mortality. There was no difference in duration of therapy in culture-negative or culture-positive sepsis, rates of necrotizing enterocolitis, or breadth of antibiotic exposure. Fewer antibiotic starts occurred during program implementation (63% versus 59%, P < 0.001). The use of narrow-spectrum agents decreased (P < 0.001) whereas the use of cefotaxime increased (P = 0.016) during program implementation.

CONCLUSIONS

Daily prospective audit and feedback was not associated with a change in antibiotic duration or clinical outcomes, however there were fewer babies started on antibiotics, suggesting that additional interventions are required to inform and sustain changes in antibiotic prescribing practices.

Early onset sepsis calculator-based management of newborns exposed to maternal intrapartum fever: a cost benefit analysis

OBJECTIVE

To determine potential net monetary benefit of an early onset sepsis calculator-based approach for management of neonates exposed to maternal intrapartum fever, compared to existing guidelines.

STUDY DESIGN

We performed a cost-benefit analysis comparing two management approaches for newborns >34 weeks gestational age exposed to maternal intrapartum fever. Probabilities of sepsis and meningitis, consequences of infection and antibiotic use, direct medical costs, and indirect costs for long-term disability and mortality were considered.

RESULTS

A calculator-based approach resulted in a net monetary benefit of $3998 per infant with a 60% likelihood of net benefit in probabilistic sensitivity analysis. Our model predicted a 67% decrease in antibiotic use in the calculator arm. The absolute difference for all adverse clinical outcomes between approaches was ≤0.6%.

CONCLUSIONS

Compared to existing guidelines, a calculator-based approach for newborns exposed to maternal intrapartum fever yields a robust net monetary benefit, largely by preventing unnecessary antibiotic treatment.

Antibiotic Overuse in Premature Low Birth Weight Infants in a Developing Country

BACKGROUND

Neonatal sepsis is a leading cause of child morbidity and mortality, especially in premature and low birth weight infants. Prompt antibiotic therapy is warranted, but its inappropriate use leads to bacterial resistance and adverse outcomes. Our objective is to describe the antibiotic use for late-onset sepsis in Peruvian premature infants.

METHODS

This study is a prospective study as a secondary analysis of a clinical trial in 3 neonatal care units in Peru. We included infants in the first 72 hours of life, with birth weight (BW) <2000 g. We described the antibiotic use as length of therapy (LOT) per 1000 patient days (PD) and antibiotic courses.

RESULTS

We included 408 neonates, with 12,204 PD of follow-up; 253 infants (62%) had a BW ≤1500 g. Total antibiotic use for late-onset sepsis was 2395 LOT (196 LOT/1000 PD). Two-hundred and seventy-one patients (66.4%) did not receive antibiotics for late-onset sepsis during their hospitalization. In total, 204 antibiotic courses were administered; 92 infants (22.5%) received 1 course, and 45 (11.0%) received 2-5 antibiotic courses. Mean duration of antibiotic course was 10.8 days (standard deviation: ±7.3). We found a significant association between a lower BW and increased antibiotic use per day (P < 0.001). The most commonly used antibiotics were vancomycin (143 LOT/1000 PD), carbapenems (115 LOT/1000 PD), aminoglycosides (72 LOT/1000 PD) and ampicillin (41 LOT/1000 PD).

CONCLUSIONS

Premature infants receive antibiotics for longer than recommended periods of time. Antibiotic overuse is greater in neonates with lower BW. Vancomycin is the most used antibiotic. There is an urgent need to develop antimicrobial stewardship programs in our setting.

Broad spectrum antibiotics in newborns increase multi-drug resistant infections

Our objective was to determine if broad spectrum antibiotics (BSA) are associated with multi-resistant bacterial (MRB) infections in neonatal patients. We conducted a case-control study with two groups of patients: those with and without a MRB infection. We included 43 cases and 43 controls. MRB strains were: 21 S. maltophila (49%), 11 ESBL-producing Enterobacteriae (25%), 8 P. aeruginosa (19%) and 3 MRSA (7%). Odds ratio (OR) for MRB after seven days of carbapenems was 4.25 (95% confidence interval (CI) 1.4-17.4) and OR for MRB after seven days of third generation cephalosporin was 8 (95% CI 1.1-34.9). BSA longer than seven days, increases MRB infections 22.5 times in patients with bronchopulmonary dysplasia (BPD). Our data show a clear association between the use of BSA and the development of MRB infections, especially in BPD. Although we cannot state this is a causal relationship, we can recommend avoiding prolonged treatment with these antibiotics in preterm babies at risk of BPD.

Antimicrobial Stewardship in the Neonatal Intensive Care Unit: An Update

Neonates represent a vulnerable population for infections and neonatal sepsis is a major cause of mortality and morbidity worldwide. Therefore, antimicrobials are the most commonly prescribed drugs in the Neonatal Intensive Care Unit Setting but unfortunately are quite often used inappropriately with various short and long-term effects. The rational use of antimicrobials is of paramount importance in this population and structured antimicrobial stewardship interventions should be in place. These interventions are slightly different from those used in adults and older children due to the particularities of the neonatal medicine. The aim of this review is to provide an update in the field and identify areas for further consideration and future research.

Urinary tract infection is common in VLBW infants

OBJECTIVE

Determine the significance of urinary tract infection (UTI) as a cause of late onset sepsis (LOS) in very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

Analysis of blood, cerebrospinal fluid and urine culture results in VLBW infants >72-h old, admitted to the Georgetown University Hospital NICU between 2005 and 2015.

RESULT

Of 527 VLBW infants, 297 (56.4%) underwent 911 evaluations for LOS; only one-third included urine cultures. UTI was diagnosed in 8.5% of VLBW infants (range 2-15.9%) and in 13.8% of infants weighing < 1000 g at birth. Gram-negative infections predominated. Concomitant blood cultures were negative in 96% of infants. UTI was more common than bloodstream infection by 2015.

CONCLUSION

UTI is a significant cause of infection in VLBW infants. Urine culture should be included in all LOS evaluations in order to facilitate accurate diagnosis and appropriate antibiotic therapy.

Antimicrobial consumption in five adult intensive care units: a 33-month surveillance study

Background

Estimating the baseline antimicrobial consumption is extremely important to monitor the impact of antimicrobial stewardship activities that aim to reduce the burden and cost of antimicrobial consumption.

Objectives

To quantify service-specific antimicrobial consumption using different metrics.

Methods

A surveillance study was conducted at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between October 2012 and June 2015 in five adult intensive care units (ICUs). Consumption data were collected manually on a daily basis by infection control practitioners. Data were presented as defined daily dose (DDD), days of therapy (DOT) per 1000 patient days, and frequency of daily consumption.

Results

A total of 43,970 DDDs and 46,940 DOTs were monitored during 54,116 patient-days. For the most frequently consumed antimicrobials, the consumption of carbapenems, piperacillin/tazobactam, vancomycin, and colistin (respectively) in all ICUs combined were 255.9, 134.3, 98.2, and 13.6 DDDs per 1000 patient-days and 235.7, 145.9, 129.5, and 117.5 DOTs per 1000 patient-days. For the frequency of daily consumption, carbapenems were the most frequently consumed antimicrobial group in medical/surgical, burn, and step-down ICUs while piperacillin/tazobactam was the most frequently consumed antimicrobial in neuro-surgical and cardio-thoracic ICUs.

Conclusion

High consumption of broad-spectrum antimicrobial agents such as meropenem and piperacillin/tazobactam is observed in multiple ICUs in a tertiary care hospital. Meropenem consumption is considerably higher than similar ICUs internationally. Future studies focusing on concurrent monitoring of antimicrobial resistance and identifying patient and physician characteristics associated with specific prescription patterns may help in improving judicious antimicrobial consumption.

Early Antibiotic Exposure and Adverse Outcomes in Preterm, Very Low Birth Weight Infants

OBJECTIVES

To determine whether antibiotic use in the first 14 postnatal days in preterm, very low birth weight (birth weight of ≤1500 g) infants is associated with risk after 14 days of age for late-onset sepsis, necrotizing enterocolitis (NEC), or death after controlling for severity of illness using the Clinical Risk Index in Babies II score, and determine whether duration of antibiotic exposure was associated with risk of adverse outcomes.

STUDY DESIGN

This retrospective cohort study included very low birth weight infants born at ≤32^6/7 weeks of gestation admitted to the neonatal intensive care unit from September 2010 to June 2014. Infants were excluded if they had major congenital anomalies or culture-proven sepsis, NEC, or death during the first 14 days of life. Antibiotic exposure was recorded as days of therapy and length of therapy in days.

RESULTS

Of 374 infants, 70 (19%) had late-onset sepsis, NEC, or death after 14 days of age. The median number of antibiotic days of therapy and length of therapy were 5.5 and 3.0, respectively. In multivariate analysis after controlling for severity of illness, each antibiotic day of therapy was associated with a 1.24 times increased risk of sepsis, NEC, or death (OR, 1.24; 95% CI, 1.17-1.31). Risk was similar when length of therapy was used (OR, 1.47; 95% CI, 1.32-1.64).

CONCLUSIONS

After controlling for severity of illness, each day of antibiotic therapy provided to preterm, very low birth weight infants in the first 2 weeks of age is associated with an increased risk of late-onset sepsis, NEC, or death.

Scaling beta-lactam antimicrobial pharmacokinetics from early life to old age

AIMS

Beta-lactam dose optimization in critical care is a current priority. We aimed to review the pharmacokinetics (PK) of three commonly used beta-lactams (amoxicillin ± clavulanate, piperacillin-tazobactam and meropenem) to compare PK parameters reported in critically and noncritically ill neonates, children and adults, and to investigate whether allometric and maturation scaling principles could be applied to describe changes in PK parameters through life.

METHODS

A systematic review of PK studies of the three drugs was undertaken using MEDLINE and EMBASE. PK parameters and summary statistics were extracted and scaled using allometric principles to 70 kg individual for comparison. Pooled data were used to model clearance maturation and decline using a sigmoidal (Hill) function.

RESULTS

A total of 130 papers were identified. Age ranged from 29 weeks to 82 years and weight from 0.9-200 kg. PK parameters from critically ill populations were reported with wider confidence intervals than those in healthy volunteers, indicating greater PK variability in critical illness. The standard allometric size and sigmoidal maturation model adequately described increasing clearance in neonates, and a sigmoidal model was also used to describe decline in older age. Adult weight-adjusted clearance was achieved at approximately 2 years postmenstrual age. Changes in volume of distribution were well described by the standard allometric model, although amoxicillin data suggested a relatively higher volume of distribution in neonates.

CONCLUSIONS

Critical illness is associated with greater PK variability than in healthy volunteers. The maturation models presented will be useful for optimizing beta-lactam dosing, although a prospective, age-inclusive study is warranted for external validation.

Blood culture indications in critically ill neonates: a multicenter prospective cohort study

Due to potential lethality of healthcare-associated sepsis (HAS), a low threshold for blood culturing and antimicrobial therapy (ABT) initiation is accepted. We assessed variability in the trigger for blood culturing between three neonatal intensive care units. A multicenter prospective cohort study was conducted. In newborns with suspicion of HAS, 10 predefined clinical signs, nosocomial sepsis (NOSEP) score, C-reactive protein, ABT initiation, and risk factors were registered at time of culturing. Outcome was lab-confirmed HAS, defined according to the NeoKISS-criteria. Two hundred ninety-nine suspected HAS episodes were considered in 212 infants, of which 118 had birth-weight ≤ 1500 g; proportion of lab-confirmed HAS per suspected episode was 30/192 (center 1), 28/60 (center 2), and 8/47 (center 3) (p < 0.001). Median C-reactive protein and number of clinical signs at time of culturing differed between centers 1, 2, and 3 (respectively 11 vs. 5 vs. 3 mg/L, p = 0.001; 1 sign [IQR 0-2, center 1] vs. 3 signs [IQR 2-4, centers 2 and 3], p < 0.001). Median NOSEP score at time of culturing was 5 (IQR 3-8, center 1), 5 (IQR 3-9, center 2), and 8 (IQR 5-11, center 3) (p = 0.016). Difference in ABT initiation was noticed (82 vs. 93 vs. 74%, p = 0.05).

CONCLUSION

Center heterogeneity in sampling practice is substantial. Optimizing sampling practice can be recommended. What is Known: • Blood culture test is a common diagnostic procedure in critically-ill newborns. • A low threshold for sampling and antimicrobial therapy initiation is accepted. What is New: • Variability in blood culture practice was assessed between 3 neonatal intensive care units by the registration of sampling frequencies, clinical indications, and antimicrobial therapy initiation.

[Research advances in rational use of antibiotics in neonates]

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

Antimicrobial Stewardship in Neonates: Challenges and Opportunities

Neonatal infections result in significant morbidity and mortality. Antibiotics are vital for the treatment of infections but disrupt the neonatal microbiome, put the infant at risk for an adverse drug reaction, and may lead to the development of antibiotic resistance. Immediately after birth, clinicians must determine which infants require empiric antibiotics. Online risk stratification tools may provide a superior approach to decision trees. In infants who require empiric therapy for early-onset sepsis, ampicillin and an aminoglycoside with dosing based on recent pharmacokinetic studies represents the most appropriate first-line agents; third-generation cephalosporins should be reserved for patients with a high likelihood of Gram-negative meningitis. An antistaphylococcal penicillin and gentamicin should be utilized for suspected late-onset sepsis. Vancomycin and other broad-spectrum agents are reserved for patients with a history of resistant organisms. Antibiotic duration should be guided by understanding the clinical indications and obtaining the necessary cultures appropriately (i.e., adequate volume blood cultures). In the absence of a positive culture, antibiotic duration should often be limited. Individual institutions should leverage a multidisciplinary, interprofessional team to identify opportunities for antimicrobial stewardship. A collaborative, transparent system is required to change unit culture and generate a sustained impact on antibiotic utilization with optimal patient outcomes.

Pediatric Antimicrobial Stewardship: State of the Art

PURPOSE OF REVIEW

We aim to systematically review the literature on the effectiveness of pediatric antimicrobial stewardship programs (ASPs) and antimicrobial stewardship (AS) strategies in the United States (US) inpatient setting. Furthermore, we review current gaps and challenges for unique pediatric populations and those in ambulatory settings.

RECENT FINDINGS

Misuse and overuse of antimicrobials have been identified as key factors for antimicrobial resistance (AR). Multiple professional organizations support the implementation of hospital-based ASPs to decrease antimicrobial consumption, improve patient outcomes, and reduce healthcare costs. There is limited data on the effectiveness of inpatient pediatric ASPs and AS strategies in unique populations. Furthermore, there is a paucity of evidence on ASPs in ambulatory settings. This review contributes to the growing body of evidence that supports the use of pediatric ASPs to optimize antimicrobial therapy in the inpatient setting as well as in unique patient populations and ambulatory settings. Active stewardship is critical and antimicrobial consumption is a key outcome metric for programs.

Outgrowing the Immaturity Myth: The Cost of Defending From Neonatal Infectious Disease

Newborns suffer high rates of mortality due to infectious disease-this has been generally regarded to be the result of an "immature" immune system with a diminished disease-fighting capacity. However, the immaturity dogma fails to explain (i) greater pro-inflammatory responses than adults in vivo and (ii) the ability of neonates to survive a significantly higher blood pathogen burden than of adults. To reconcile the apparent contradiction of clinical susceptibility to disease and the host immune response findings when contrasting newborn to adult, it will be essential to capture the entirety of available host-defense strategies at the newborn's disposal. Adults focus heavily on the disease resistance approach: pathogen reduction and elimination. Newborn hyperactive innate immunity, sensitivity to immunopathology, and the energetic requirements of growth and development (immune and energy costs), however, preclude them from having an adult-like resistance response. Instead, newborns also may avail themselves of disease tolerance (minimizing immunopathology without reducing pathogen load), as a disease tolerance approach provides a counterbalance to the dangers of a heightened innate immunity and has lower-associated immune costs. Further, disease tolerance allows for the establishment of a commensal bacterial community without mounting an unnecessarily dangerous immune resistance response. Since disease tolerance has its own associated costs (immune suppression leading to unchecked pathogen proliferation), it is the maintenance of homeostasis between disease tolerance and disease resistance that is critical to safe and effective defense against infections in early life. This paradigm is consistent with nearly all of the existing evidence.

Quantitative Analysis of Gentamicin Exposure in Neonates and Infants Calls into Question Its Current Dosing Recommendations

Optimal dosing of gentamicin in neonates is still a matter of debate despite its common use. We identified gentamicin dosing regimens from eight international guidelines and seven Swiss neonatal intensive care units. The dose per administration, the dosing interval, the total daily dose, and the demographic characteristics between guidelines were compared. There was considerable variability with respect to dose (4 to 6 mg/kg), dosing interval (24 h to 48 h), total daily dose (2.5 to 6 mg/kg/day), and patient demographic characteristics that were used to calculate individualized dosing regimens. A model-based simulation study in 1071 neonates was performed to determine the achievement of efficacious peak gentamicin concentrations according to predefined MICs (Cmax/MIC ≥ 10) and safe trough concentrations (Cmin ≤ 2 mg/liter) with recommended dosing regimens. MIC targets of 0.5 and 1 mg/liter were used. Dosing optimization was performed giving priority to the first day of treatment and with the goal of simplifying dosing. Current gentamicin neonatal guidelines allow to achieve effective peak concentrations for MICs ≤ 0.5 mg/liter but not higher. Model-based simulations indicate that to attain peak gentamicin concentrations of ≥10 mg/liter, a dose of 7.5 mg/kg should be administered using an extended dosing interval regimen. Trough concentrations of ≤2 mg/liter can be maintained with a dosing interval of 36 to 48 h in neonates according to gestational and postnatal age. For treatment beyond 3 days, therapeutic drug monitoring is advised to maintain adequate serum concentrations.

Neonatal Ventilator Associated Pneumonia: A Quality Improvement Initiative Focusing on Antimicrobial Stewardship

Background and Aims: Neonatal ventilator associated pneumonia (VAP) is a common nosocomial infection and a frequent reason for empirical antibiotic therapy in NICUs. Nonetheless, there is no international consensus regarding diagnostic criteria and management. In a first step, we analyzed the used diagnostic criteria, risk factors and therapeutic management of neonatal VAP by a literature review. In a second step, we aimed to compare suspected vs. confirmed neonatal VAP episodes in our unit according to different published criteria and to analyze interrater-reliability of chest x-rays. Additionally, we aimed to evaluate the development of VAP incidence and antibiotic use after implementation of multifaceted quality improvement changes regarding antimicrobial stewardship and infection control (VAP-prevention-bundle, early-extubation policy, antimicrobial stewardship rounds). Methods: Neonates until 44 weeks of gestation with suspected VAP, hospitalized at our level-III NICU in Lucerne from September 2014 to December 2017 were enrolled. VAP episodes were analyzed according to 4 diagnostic frameworks. Agreement regarding chest x-ray interpretation done by 10 senior physicians was assessed. Annual incidence of suspected and confirmed neonatal VAP episodes and antibiotic days were calculated and compared for the years 2015, 2016, and 2017. Results: 17 studies were identified in our literature review. Overall, CDC-guidelines or similar criteria, requesting radiographic changes as main criteria, are mostly used. Comparison of suspected vs. confirmed neonatal VAP episodes showed a great variance (20.4 vs. 4.5/1,000 ventilator-days). The interrater-reliability of x-ray interpretation was poor (intra-class correlation 0.25). Implemented changes resulted in a gradual decline in annual VAP incidence and antibiotic days from 2015 compared with 2017 (28.8 vs. 7.4 suspected episodes/1,000 ventilator-days, 5.5 vs. 0 confirmed episodes/1,000 ventilator-days and 211 vs. 34.7 antibiotic days/1,000 ventilation-days, respectively). Conclusion: The incidence of suspected VAP and concomitant antibiotic use is much higher than for confirmed VAP, therefore inclusion of suspected episodes should be considered for accurate evaluation. There is a high diagnostic inconsistency and a low reliability of interpretation of chest x-rays regarding VAP. Implementation of combined antimicrobial stewardship and infection control measures may lead to an effective decrease in VAP incidence and antibiotic use.

Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature Review

Background: Antimicrobial stewardship (AMS) is an important strategy of quality improvement for every hospital. Leadership is an important factor for implementation of quality improvement and AMS programs. Recent publications show successful AMS programs in children's hospitals, but successful implementation is often difficult to achieve and literature of AMS in neonatal and pediatric intensive care units (NICU/PICU) is scarce. Lack of resources and prescriber opposition are reported barriers. A leadership style focusing on empowering frontline staff to take responsibility is one approach to implement changes in health care institutions. Aim: Literature review regarding empowering leadership and AMS in health care and assessment of the impact of such a leadership style on AMS in a NICU/PICU over 3 years. Methods: Assessment of the impact of a leadership change September 1, 2015 from control-driven to an empowering leadership style on antibiotic use and hospital acquired infections. Prospective analysis and annual comparison of antibiotic use, rate of suspected and confirmed ventilator-associated pneumonia (VAP) and central-line associated blood stream infection (CLABSI) including antibiotic use overall, antibiotic therapy for culture-negative and culture-proven infections including correct initial choice and streamlining of antibiotics in the NICU/PICU of the Children's Hospital of Lucerne between January 1, 2015 and December 31, 2017. Results: Five articles were included in the literature review. All five studies concluded that an empowering leadership style may lead to a higher engagement of physicians. Three out of five studies reported improved AMS as reduced rate in hospital-acquired infections and improved prevention of MRSA infections. From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations (suspected infections and prophylaxis) per 1000 patient days declined significantly from 474.1 to 403.9 and from 418.2 to 309.4 days, respectively. Similar, the use of meropenem and vancomycin declined significantly. Over the 3 years, suspected and proven VAP- and CLABSI-episodes decreased with no confirmed episodes in 2017. Conclusion: An empowering leadership style which focuses on enabling frontline physicians to take direct responsibilities for their patients may be a successful strategy of antimicrobial stewardship allowing to overcome reported barriers of AMS implementation.

The Neonatal Microbiome: Implications for Neonatal Intensive Care Unit Nurses

Nursing care of the neonate in the neonatal intensive care unit (NICU) is complex, due in large part to various physiological challenges. A newer and less well-known physiological consideration is the neonatal microbiome, the community of microorganisms, both helpful and harmful, that inhabit the human body. The neonatal microbiome is influenced by the maternal microbiome, mode of infant birth, and various aspects of NICU care such as feeding choice and use of antibiotics. The composition and diversity of the microbiome is thought to influence key health outcomes including development of necrotizing enterocolitis, late-onset sepsis, altered physical growth, and poor neurodevelopment. Nurses in the NICU play a key role in managing care that can positively influence the microbiome to promote more optimal health outcomes in this vulnerable population of newborns.

Newborn susceptibility to infection vs. disease depends on complex in vivo interactions of host and pathogen

The burden of newborn infectious disease has long been recognized as the highest across the entire human life span. The precise underlying cause is unfortunately still far from clear. A substantial body of data derived mostly from in vitro experimentation indicates "lower" host immune responses in early vs. adult life and is briefly summarized within this review. However, emerging data derived mostly from in vivo experimentation reveal that the newborn host also exhibits an exuberant immune and inflammatory response following infection when compared to the adult. In this context, it is important to emphasize that "infection" does not equate "infectious disease," as for many infections it is the host response to the infection that causes disease. This simple insight readily arranges existing evidence into cause-effect relationships that explain much of the increase in clinical suffering from infection in early life. We here briefly summarize the evidence in support of this paradigm and highlight the important implications it has for efforts to ameliorate the suffering and dying from infection in early life.

Prevalence, Characteristics, and Perception of Nursery Antibiotic Stewardship Coverage in the United States

BACKGROUND

Prolonged or unnecessary antibiotic use is associated with adverse outcomes in infants. Antibiotic stewardship programs (ASPs) aim to prevent these adverse outcomes and optimize antibiotic prescribing. However, data evaluating ASP coverage of nurseries are limited. The objectives of this study were to describe the characteristics of nurseries with and without ASP coverage and to determine perceptions of and barriers to nursery ASP coverage.

METHODS

The 2014 American Hospital Association annual survey was used to randomly select a level III neonatal intensive care unit from all 50 states. A level I and level II nursery from the same city as the level III nursery were then randomly selected. Hospital, nursery, and ASP characteristics were collected. Nursery and ASP providers (pharmacists or infectious disease providers) were interviewed using a semistructured template. Transcribed interviews were analyzed for themes.

RESULTS

One hundred forty-six centers responded; 104 (71%) provided nursery ASP coverage. In multivariate analysis, level of nursery, university affiliation, and number of full-time equivalent ASP staff were the main predictors of nursery ASP coverage. Several themes were identified from interviews: unwanted coverage, unnecessary coverage, jurisdiction issues, need for communication, and a focus on outcomes. Most providers had a favorable view of nursery ASP coverage.

CONCLUSIONS

Larger, higher-acuity nurseries in university-affiliated hospitals are more likely to have ASP coverage. Low ASP staffing and a perceived lack of importance were frequently cited as barriers to nursery coverage. Most nursery ASP coverage is viewed favorably by providers, but nursery providers regard it as less important than ASP providers.

Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit

OBJECTIVE

To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP).

DESIGN

Quasi-experimental, interrupted time-series study.

SETTING

A 54-bed, level IV NICU in a regional academic and tertiary referral center.

PATIENTS AND PARTICIPANTS

All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion.

INTERVENTION

Implementation of a NICU-specific ASP beginning July 2012.

METHODS

We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance.

RESULTS

Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time.

CONCLUSIONS

Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices.

Infect Control Hosp Epidemiol 2017;38:1137–1143

Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units

AIM

Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens.

METHODS

The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014.

RESULTS

All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice.

CONCLUSIONS

There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.

Immunological Defects in Neonatal Sepsis and Potential Therapeutic Approaches

Despite advances in critical care medicine, neonatal sepsis remains a major cause of morbidity and mortality worldwide, with the greatest risk affecting very low birth weight, preterm neonates. The presentation of neonatal sepsis varies markedly from its presentation in adults, and there is no clear consensus definition of neonatal sepsis. Previous work has demonstrated that when neonates become septic, death can occur rapidly over a matter of hours or days and is generally associated with inflammation, organ injury, and respiratory failure. Studies of the transcriptomic response by neonates to infection and sepsis have led to unique insights into the early proinflammatory and host protective responses to sepsis. Paradoxically, this early inflammatory response in neonates, although lethal, is clearly less robust relative to children and adults. Similarly, the expression of genes involved in host protective immunity, particularly neutrophil function, is also markedly deficient. As a result, neonates have both a diminished inflammatory and protective immune response to infection which may explain their increased risk to infection, and their reduced ability to clear infections. Such studies imply that novel approaches unique to the neonate will be required for the development of both diagnostics and therapeutics in this high at-risk population.