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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024; 404:277-293. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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2
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Saunders M, Ojha S, Szatkowski L. Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326983. [PMID: 38802167 DOI: 10.1136/archdischild-2024-326983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To assess the impact of publication of UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention and treatment of early-onset infections (EOIs) in neonates (clinical guideline 149 (CG149), published in 2012, and its 2021 update (NG195) on antibiotic use in very preterm infants. DESIGN Interrupted time series analysis using data from the National Neonatal Research Database. SETTING Neonatal units in England and Wales. PARTICIPANTS Infants born at 22-31 weeks' gestation from 1 January 2010 to 31 December 2022 and survived to discharge. INTERVENTIONS Publication of CG149 (August 2012) and NG195 (April 2021). MAIN OUTCOME MEASURES Measures of antibiotic use, aggregated by month of birth: antibiotic use rate (AUR), the proportion of care days in receipt of at least one antibiotic; percentage of infants who received ≥1 day of antibiotics on days 1-3 for EOI and after day 3 for late-onset infection (LOI); percentage who received ≥1 prolonged antibiotic course ≥5 days for EOI and LOI. RESULTS 96% of infants received an antibiotic during inpatient stay. AUR declined at publication of CG149, without further impact at NG195 publication. There was no impact of CG149 on the underlying trend in infants receiving ≥1 day antibiotics for EOI or LOI, but post-NG195 the monthly trend began to decline for EOI (-0.20%, -0.26 to -0.14) and LOI (-0.23%, -0.33 to -0.12). Use of prolonged antibiotic courses for EOI and LOI declined at publication of CG149 and for LOI this trend accelerated post-NG195. CONCLUSIONS Publications of NICE guidance were associated with reductions in antibiotic use; however neonatal antibiotic exposure remains extremely high.
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Affiliation(s)
- Mike Saunders
- University of Nottingham School of Medicine, Nottingham, UK
| | - Shalini Ojha
- Centre for Perinatal Research, University of Nottingham School of Medicine, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Lisa Szatkowski
- Centre for Perinatal Research, University of Nottingham School of Medicine, Nottingham, UK
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Martin L, Pecar A, Baltaci Y, Simon A, Kohl S, Müller D, Forster J. [Potential Nephrotoxicity of Combination of Vancomycin and Piperacillin-Tazobactam: Recommendations from the AG ABS of the DGPI supported by experts of the GPN]. KLINISCHE PADIATRIE 2024. [PMID: 38458232 DOI: 10.1055/a-2244-7698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
The combination of vancomycin and piperacillin/tazobactam (V+P/T) is used for empirical antibiotic treatment of severe infections, especially in immunocompromised patients and those colonized with multidrug-resistant bacteria. Nephrotoxicity is a frequently observed adverse effect of vancomycin. Its risk can be reduced by therapeutic drug monitoring and adjusted dosing. Piperacillin/tazobactam (P/T) rarely causes interstitial nephritis. The results of retrospective cohort studies in children predominantly show a low, clinically irrelevant, additive nephrotoxicity (defined as an increase in creatinine in the serum) of both substances. Due to the limitations of the existing publications, the ABS working group of the DGPI and experts of the GPN do not recommend against the use of P/T plus vancomycin. Preclinical studies and a prospective study with adult patients, which evaluated different renal function tests as well as clinical outcomes, do not support previous findings of additive nephrotoxicity. Time-restricted use of V+P/T can minimize exposure and the potential risk of nephrotoxicity. Local guidelines, developed in collaboration with the antibiotic stewardship team, should define the indications for empirical and targeted use of P/T and V+P/T. When using combination therapy with V+P/T, kidney function should be monitored through clinical parameters (volume status, balancing, blood pressure) as well as additional laboratory tests such as serum creatinine and cystatin C.
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Affiliation(s)
- Luise Martin
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alenka Pecar
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Germany
| | - Yeliz Baltaci
- Klinik für Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Arne Simon
- Klinik für Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Stefan Kohl
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Abteilung für Kindernephrologie, Uniklinik Köln, Köln, Germany
| | - Dominik Müller
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Forster
- Institut für Hygiene und Mikrobiologie, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
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Huncikova Z, Stensvold HJ, Øymar KAA, Vatne A, Lang AM, Støen R, Brigtsen AK, Moster D, Eriksen BH, Selberg T, Rønnestad A, Klingenberg C. Variation in antibiotic consumption in very preterm infants-a 10 year population-based study. J Antimicrob Chemother 2024; 79:143-150. [PMID: 37986613 PMCID: PMC10761275 DOI: 10.1093/jac/dkad358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES Wide variations in antibiotic use in very preterm infants have been reported across centres despite similar rates of infection. We describe 10 year trends in use of antibiotics and regional variations among very preterm infants in Norway. PATIENTS AND METHODS All live-born very preterm infants (<32 weeks gestation) admitted to any neonatal unit in Norway during 2009-18 were included. Main outcomes were antibiotic consumption expressed as days of antibiotic therapy (DOT) per 1000 patient days (PD), regional variations in use across four health regions, rates of sepsis and sepsis-attributable mortality and trends of antibiotic use during the study period. RESULTS We included 5296 infants: 3646 (69%) were born at 28-31 weeks and 1650 (31%) were born before 28 weeks gestation with similar background characteristics across the four health regions. Overall, 80% of the very preterm infants received antibiotic therapy. The most commonly prescribed antibiotics were the combination of narrow-spectrum β-lactams and aminoglycosides, but between 2009 and 2018 we observed a marked reduction in their use from 100 to 40 DOT per 1000 PD (P < 0.001). In contrast, consumption of broad-spectrum β-lactams remained unchanged (P = 0.308). There were large variations in consumption of vancomycin, broad-spectrum β-lactams and first-generation cephalosporins, but no differences in sepsis-attributable mortality across regions. CONCLUSIONS The overall antibiotic consumption was reduced during the study period. Marked regional variations remained in consumption of broad-spectrum β-lactams and vancomycin, without association to sepsis-attributable mortality. Our results highlight the need for antibiotic stewardship strategies to reduce consumption of antibiotics that may enhance antibiotic resistance development.
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Affiliation(s)
- Zuzana Huncikova
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Asbjørn Alexander Øymar
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anlaug Vatne
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
| | - Astri Maria Lang
- Paediatric Department, Akershus University Hospital, Lørenskog, Norway
| | - Ragnhild Støen
- Department of Paediatrics, St.Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Karin Brigtsen
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Dag Moster
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje Selberg
- Department of Paediatric and Adolescent Medicine, Ostfold County Hospital, Gralum, Norway
| | - Arild Rønnestad
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Paediatric and Adolescent Medicine, Ostfold County Hospital, Gralum, Norway
- Medical Faculty, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claus Klingenberg
- Department of Paediatrics and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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5
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Keij FM, Schouwenburg S, Kornelisse RF, Preijers T, Mir F, Degraeuwe P, Stolk LM, van Driel A, Kenter S, van der Sluijs J, Heidema J, den Butter PCP, Reiss IKM, Allegaert K, Tramper-Stranders GA, Koch BCP, Flint RB. Oral and Intravenous Amoxicillin Dosing Recommendations in Neonates: A Pooled Population Pharmacokinetic Study. Clin Infect Dis 2023; 77:1595-1603. [PMID: 37757471 PMCID: PMC10686957 DOI: 10.1093/cid/ciad432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND There is a lack of evidence on oral amoxicillin pharmacokinetics and exposure in neonates with possible serious bacterial infection (pSBI). We aimed to describe amoxicillin disposition following oral and intravenous administration and to provide dosing recommendations for preterm and term neonates treated for pSBI. METHODS In this pooled-population pharmacokinetic study, 3 datasets were combined for nonlinear mixed-effects modeling. In order to evaluate amoxicillin exposure following oral and intravenous administration, pharmacokinetic profiles for different dosing regimens were simulated with the developed population pharmacokinetic model. A target of 50% time of the free fraction above the minimal inhibitory concentration (MIC) with an MICECOFF of 8 mg/L (to cover gram-negative bacteria such as Escherichia coli) was used. RESULTS The cohort consisted of 261 (79 oral, 182 intravenous) neonates with a median (range) gestational age of 35.8 weeks (range, 24.9-42.4) and bodyweight of 2.6 kg (range, 0.5-5). A 1-compartment model with first-order absorption best described amoxicillin pharmacokinetics. Clearance (L/h/kg) in neonates born after 30 weeks' gestation increased with increasing postnatal age (PNA day 10, 1.25-fold; PNA day 20, 1.43-fold vs PNA day 3). Oral bioavailability was 87%. We found that a twice-daily regimen of 50 mg/kg/day is superior to a 3- or 4-times daily schedule in the first week of life for both oral and intravenous administration. CONCLUSIONS This pooled population pharmacokinetic description of intravenous and oral amoxicillin in neonates provides age-specific dosing recommendations. We conclude that neonates treated with oral amoxicillin in the first weeks of life reach adequate amoxicillin levels following a twice-daily dosing regimen. Oral amoxicillin therapy could therefore be an adequate, cost-effective, and more patient-friendly alternative for neonates worldwide.
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Affiliation(s)
- Fleur M Keij
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - René F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim Preijers
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Fatima Mir
- Section of Paediatric Infectious Disease, Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Pieter Degraeuwe
- Department of Paediatrics, Division of Neonatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Leo M Stolk
- Department of Clinical Pharmacy, Maastricht University Medical Centre, The Netherlands
| | - Arianne van Driel
- Department of Paediatrics, IJsselland Hospital, Capelle a/d IJssel, The Netherlands
| | - Sandra Kenter
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Jacqueline van der Sluijs
- Department of Paediatrics, Division of Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Jojanneke Heidema
- Department of Paediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Irwin K M Reiss
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Gerdien A Tramper-Stranders
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Paediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robert B Flint
- Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre–Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, The Netherlands
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6
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Poggi C, Dani C. New Antimicrobials for the Treatment of Neonatal Sepsis Caused by Multi-Drug-Resistant Bacteria: A Systematic Review. Antibiotics (Basel) 2023; 12:956. [PMID: 37370275 DOI: 10.3390/antibiotics12060956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Infections by multi-drug-resistant (MDR) organisms are sharply increasing in newborns worldwide. In low and middle-income countries, a disproportionate amount of neonatal sepsis caused by MDR Gram negatives was recently reported. Newborns with infections by MDR organisms with limited treatment options may benefit from novel antimicrobials. METHODS We performed a literature search investigating the use in newborns, infants and children of novel antimicrobials for the treatment of MDR Gram negatives, namely ceftazidime/avibactam, ceftolozane/tazobactam, cefiderocol, meropenem/vaborbactam, imipenem/relebactam, and Gram positives with resistance of concern, namely ceftaroline and dalbavancin. PubMed, EMBASE, and Web of Science were searched. RESULTS A total of 50 records fulfilled the inclusion criteria. Most articles were case reports or case series, and ceftazidime/avibactam was the most studied agent. All studies showed favorable efficacy and safety profile in newborns and across different age cohorts. CONCLUSIONS novel antibiotics may be considered in newborns for the treatment of MDR Gram negatives with limited treatment options and for Gram positives with resistance concerns. Further studies are needed to address their effectiveness and safety in newborns.
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Affiliation(s)
- Chiara Poggi
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, 50141 Florence, Italy
| | - Carlo Dani
- Neonatal Intensive Care Unit, Department of Mother and Child Care, Careggi University Hospital, 50141 Florence, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, 50141 Florence, Italy
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Abstract
Neonatal late-onset sepsis (LOS) continues to threaten morbidity and mortality in the NICU and poses ongoing diagnostic and therapeutic challenges. Early recognition of clinical signs, rapid evaluation, and prompt initiation of treatment are critical to prevent life-threatening deterioration. Preterm infants-born at ever-decreasing gestational ages-are at particularly high risk for life-long morbidities and death. This changing NICU population necessitates continual reassessments of diagnostic and preventive measures and evidence-based treatment for LOS. The clinical presentation of LOS is varied and nonspecific. Despite ongoing research, reliable, specific laboratory biomarkers facilitating early diagnosis are lacking. These limitations drive an ongoing practice of liberal initiation of empiric antibiotics among infants with suspected LOS. Subsequent promotion of multidrug-resistant microorganisms threatens the future of antimicrobial therapy and puts preterm and chronically ill infants at even higher risk of nosocomial infection. Efforts to identify adjunctive therapies counteracting sepsis-driven hyperinflammation and sepsis-related functional immunosuppression are ongoing. However, most approaches have either failed to improve LOS prognosis or are not yet ready for clinical application. This article provides an overview of the epidemiology, risk factors, diagnostic tools, and treatment options of LOS in the context of increasing numbers of extremely preterm infants. It addresses the question of whether LOS could be identified earlier and more precisely to allow for earlier and more targeted therapy and discusses rational approaches to antibiotic therapy to avoid overuse. Finally, this review elucidates the necessity of long-term follow-up of infants with a history of LOS.
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Affiliation(s)
- Sarah A. Coggins
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kirsten Glaser
- Division of Neonatology, Department of Women’s and Children’s Health, University of Leipzig Medical Center, Leipzig, Germany
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8
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Kramer TS, Salm F, Schwab F, Geffers C, Behnke M, Gastmeier P, Piening B. Reduction of antibacterial use in patients with very low birth weight on German NICUs after implementation of a mandatory surveillance system. A longitudinal study with national data from 2013 to 2019. J Infect 2022; 85:8-16. [DOI: 10.1016/j.jinf.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/02/2021] [Accepted: 05/10/2022] [Indexed: 11/17/2022]
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9
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Kolberg L, Buschbeck J, Wagner A, Jonat S, Wolf G, Peters J, Behrends U, Steinhauser M, Huebner J, von Both U. Evaluating current practice and knowledge about antibiotic stewardship principles in paediatric tertiary hospitals to identify target areas for future teaching activities. Infection 2022; 50:1273-1279. [PMID: 35366158 PMCID: PMC9522681 DOI: 10.1007/s15010-022-01807-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Antibiotic exposure among hospitalized children is very high. With inappropriate antimicrobial use resulting in increased rates of antimicrobial resistance, the implementation of antibiotic stewardship programs is critically needed. This survey study aimed to identify current practice and knowledge about antibiotic stewardship and infection control among paediatricians in tertiary care paediatric hospitals in and around Munich, Germany. METHODS A prospective cross-sectional study based on an anonymous questionnaire, structured into different sub-sections regarding antibiotic use, antimicrobial resistance, antibiotic stewardship and infection control, was conducted between 1st of May and 30th of June 2016 in five paediatric hospitals. RESULTS In total, 111 paediatricians across all grades were eligible for participation. The overall proportion of correct answers for all sub-sections of the survey ranged from 54.1% correct answers in the antibiotic handling and bacterial resistance section to 72.9% correct answers in the hospital hygiene/infection control section. In general, knowledge across all categories was similar for junior doctors, middle-grade doctors or consultants. Advocating empiric use of narrow-spectrum instead of broad-spectrum antibiotics was considered to be the most difficult measure to implement in daily practice (36.9%). De-escalation from broad-spectrum empirical therapy to targeted treatment was considered the easiest measure to achieve (43.2%). CONCLUSION Our results demonstrate that principles of antimicrobial stewardship and aspects of hospital hygiene/infection control are not satisfactorily known among hospital-based paediatricians in and around Munich. We identified four important target areas for future educational interventions that should play a more prominent role in both pre- and postgraduate medical training.
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Affiliation(s)
- Laura Kolberg
- Department of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians University, Lindwurmstr. 4, 80337, Munich, Germany.
| | - Judith Buschbeck
- Department of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians University, Lindwurmstr. 4, 80337, Munich, Germany
| | - Annabelle Wagner
- Department of Paediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Susanne Jonat
- Department of Paediatrics, Clinic Starnberg, Starnberg, Germany
| | - Gerhard Wolf
- Department of Paediatrics, Children's Hospital Traunstein, Ludwig-Maximilians University, Munich, Germany
| | - Jochen Peters
- Department of Paediatrics, Dritter Orden Clinic, Munich, Germany
| | - Uta Behrends
- Department of Paediatrics, School of Medicine, Schwabing Municipal Hospital, Technical University of Munich, Munich, Germany.,German Center for Infection Research (DZIF) Partner Site Munich, Munich, Germany
| | - Maximilian Steinhauser
- Department of Paediatrics, School of Medicine, Schwabing Municipal Hospital, Technical University of Munich, Munich, Germany
| | - Johannes Huebner
- Department of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians University, Lindwurmstr. 4, 80337, Munich, Germany.,German Center for Infection Research (DZIF) Partner Site Munich, Munich, Germany
| | - Ulrich von Both
- Department of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, Ludwig-Maximilians University, Lindwurmstr. 4, 80337, Munich, Germany.,German Center for Infection Research (DZIF) Partner Site Munich, Munich, Germany
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10
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Do Not Act Fast and Furious. Pediatr Infect Dis J 2022; 41:e65-e66. [PMID: 35017456 DOI: 10.1097/inf.0000000000003363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
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12
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Garrido F, Allegaert K, Arribas C, Villamor E, Raffaeli G, Paniagua M, Cavallaro G. Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey. Antibiotics (Basel) 2021; 10:antibiotics10091046. [PMID: 34572631 PMCID: PMC8469483 DOI: 10.3390/antibiotics10091046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.
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Affiliation(s)
- Felipe Garrido
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
- Correspondence: ; Tel.: +34-661214947
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Cristina Arribas
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), 6229 Maastricht, The Netherlands;
| | - Genny Raffaeli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Miren Paniagua
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
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13
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Marissen J, Fortmann I, Humberg A, Rausch TK, Simon A, Stein A, Schaible T, Eichhorn J, Wintgens J, Roll C, Heitmann F, Herting E, Göpel W, Härtel C. Vancomycin-induced ototoxicity in very-low-birthweight infants. J Antimicrob Chemother 2021; 75:2291-2298. [PMID: 32464660 DOI: 10.1093/jac/dkaa156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Vancomycin is an extensively used anti-infective drug in neonatal ICUs. However, exposure-toxicity relationships have not been clearly defined. OBJECTIVES To evaluate the risk profile for hearing deficits in vancomycin-exposed very-low-birthweight infants (VLBWI). METHODS In a large cohort study of the German Neonatal Network (GNN; n = 16 967 VLBWI) we assessed the association of vancomycin treatment and pathological hearing tests at discharge and at 5 year follow-up. We performed audits on vancomycin exposure, drug levels, dose adjustments and exposure to other ototoxic drugs in a subgroup of 1042 vancomycin-treated VLBWI. RESULTS In the GNN cohort, 28% (n = 4739) were exposed to IV vancomycin therapy. In multivariable logistic regression analysis, vancomycin exposure proved to be independently associated with pathological hearing test at discharge (OR 1.18, 95% CI 1.03-1.34, P = 0.016). Among vancomycin-treated infants, a cumulative vancomycin dose above the upper quartile (>314 mg/kg bodyweight) was associated with pathological hearing test at discharge (OR 2.1, 95% CI 1.21-3.64, P = 0.009), whereas a vancomycin cumulative dose below the upper quartile was associated with a reduced risk of pathological tone audiometry results at 5 years of age (OR 0.29, 95% CI 0.1-0.8, P = 0.02, n = 147). CONCLUSIONS Vancomycin exposure in VLBWI is associated with an increased, dose-dependent risk of pathological hearing test results at discharge and at 5 years of age. Prospective studies on long-term hearing impairment are needed.
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Affiliation(s)
- Janina Marissen
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Ingmar Fortmann
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Alexander Humberg
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Tanja K Rausch
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany.,Institute of Medical Biometry and Statistics, University of Luebeck, Luebeck, Germany
| | - Arne Simon
- Department of Paediatric Oncology, Saar University Homburg, Homburg, Germany
| | - Anja Stein
- Department of Paediatrics, University of Essen, Essen, Germany
| | - Thomas Schaible
- Department of Paediatrics, University of Mannheim, Mannheim, Germany
| | | | - Jürgen Wintgens
- Children's Hospital Mönchengladbach, Mönchengladbach, Germany
| | - Claudia Roll
- Vestische Children's Hospital Datteln, Datteln, Germany
| | | | - Egbert Herting
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Wolfgang Göpel
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Christoph Härtel
- Department of Paediatrics, University of Luebeck, University Hospital of Schleswig-Holstein, Luebeck, Germany.,Department of Paediatrics, University of Wuerzburg, Wuerzburg, Germany
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14
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Simon A, Zemlin M, Geipel M, Gärtner B, Armann J, Meyer S. [Infection prevention in neonatal intensive care units]. DER GYNAKOLOGE 2021; 54:428-434. [PMID: 33967301 PMCID: PMC8094126 DOI: 10.1007/s00129-021-04804-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/09/2021] [Indexed: 12/24/2022]
Abstract
In diesem Beitrag werden einige Besonderheiten der Infektionsprävention bei intensivmedizinisch behandelten Früh und Neugeborenen dargestellt. Ergänzend finden sich Hinweise zum krankenhaushygienischen Management der SARS-CoV-2(„severe acute respiratory syndrome coronavirus 2“)-Pandemie und zur Antibiotic Stewardship in der neonatologischen Intensivmedizin.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Kirrberger Str. 9, Geb. 9, 66421 Homburg/Saar, Deutschland
| | - Michael Zemlin
- Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Martina Geipel
- Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Barbara Gärtner
- Institut für Medizinische Mikrobiologie und Hygiene (IMMH), Universität und Universitätsklinikums des Saarlandes, Homburg/Saar, Deutschland
| | - Jakob Armann
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - Sascha Meyer
- Allgemeine Pädiatrie und Neonatologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
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15
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Marissen J, Erdmann H, Böckenholt K, Hoppenz M, Rausch TK, Härtel C, Herting E, Göpel W. Aminoglycosides were associated with higher rates of surgical patent ductus arteriosus closure in preterm infants. Acta Paediatr 2021; 110:826-832. [PMID: 32810301 DOI: 10.1111/apa.15541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/27/2020] [Accepted: 08/17/2020] [Indexed: 01/03/2023]
Abstract
AIM In animal studies, aminoglycosides induced ductus arteriosus relaxation in a dose-dependent fashion. We tested the hypothesis that antibiotic treatment of preterm infants with aminoglycosides is associated with higher rates of surgical patent ductus arteriosus (PDA) closure. METHODS Preterm infants (birthweight <1000 grams or gestational age <29 weeks) enrolled in 62 German neonatal intensive care units (NICUs) were analysed. NICUs were stratified according to the use of aminoglycosides as first-line antibiotics. RESULTS Baseline data were not different when NICUs using aminoglycosides (n = 9965 infants) were compared to NICUs using other antibiotics (n = 1948 infants). Rates of surgical PDA closure were 5.9% for NICUs using aminoglycosides; 6.2% for units using gentamicin; and 5.0% for NICUs using tobramycin compared to 4.1% in NICUs using other antibiotics (P < .001, P < .001 and P = .140, respectively, Fisher's exact test). Indomethacin and ibuprofen use was more common in NICUs using aminoglycosides (41% vs 33%, P < .001, Fisher's exact test). Gentamicin trough levels were higher in NICUs with surgical closure rates above the mean (median 2.0 µg/mL, inter-quartile range 0.8-4.0 µg/mL vs 1.2 µg/mL, IQR 0.8-1.7, P < .001, Mann-Whitney U test). CONCLUSION First-line antibiotic treatment of preterm infants with aminoglycosides was associated with higher rates of surgical PDA closure.
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Affiliation(s)
- Janina Marissen
- Department of Paediatrics University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
| | - Harald Erdmann
- Hospital Pharmacy Department University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
| | | | - Marc Hoppenz
- Children's Hospital Amsterdamer Strasse Cologne Germany
| | - Tanja K. Rausch
- Department of Paediatrics University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
- Institute of Medical Biometry and Statistics University of Luebeck Luebeck Germany
| | - Christoph Härtel
- Department of Paediatrics University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
- Department of Paediatrics University of Wuerzburg Wuerzburg Germany
| | - Egbert Herting
- Department of Paediatrics University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
| | - Wolfgang Göpel
- Department of Paediatrics University Hospital of Schleswig‐Holstein University of Luebeck Luebeck Germany
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16
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Zhao Z, Zhang J. Lower Expression of miR-26a in PBMCs Indicates the Occurrence of Early-Onset Neonatal Sepsis and Is Partly Mediated by the Upregulation of PTEN. Front Pediatr 2021; 9:678205. [PMID: 34504813 PMCID: PMC8422988 DOI: 10.3389/fped.2021.678205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/16/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: It is difficult to identify neonatal sepsis early due to the lack of specific markers. The aim of the present study was to explore whether miR-26a expression in peripheral blood mononuclear cells (PBMCs) could be used as a diagnostic marker of the disease and whether phosphatase and tensin homolog (PTEN) was involved in suppressing miR-26a expression. Methods: A total of 51 early-onset septic newborns and 102 healthy newborns were included. Blood specimens were collected from septic newborns at the time of clinical diagnosis (baseline) and again between 72 and 96 h after birth. Blood specimens were collected from healthy newborns on admission. The expressions of miR-26a and PTEN in PBMCs were measured using real-time quantitative PCR (RT-qPCR). Other data, including hemoculture, were collected from medical records. Results: In septic newborns with and without a positive hemoculture, a lower baseline level of miR-26a in PBMCs was associated with a higher risk of disease. Additionally, at baseline, there was a certain linear relationship between the levels of miR-26a and two serological inflammatory markers (i.e., white blood cell count and C-reactive protein level) in septic newborns. In addition, the baseline expressions of miR-26a and PTEN showed a reverse linear relationship. Compared with those at baseline, the expression of miR-26a was higher and the expression of PTEN was lower in septic newborns starting at 72 h after birth. Conclusion: A lower baseline miR-26a expression in PBMCs indicated the occurrence of early-onset neonatal sepsis, and a reduced miR-26a expression might be partly related to the inflammatory process and PTEN upregulation.
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Affiliation(s)
- Ziyan Zhao
- Department of Pediatrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiajie Zhang
- Department of Pediatrics, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
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17
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Keij FM, Achten NB, Tramper-Stranders GA, Allegaert K, van Rossum AMC, Reiss IKM, Kornelisse RF. Stratified Management for Bacterial Infections in Late Preterm and Term Neonates: Current Strategies and Future Opportunities Toward Precision Medicine. Front Pediatr 2021; 9:590969. [PMID: 33869108 PMCID: PMC8049115 DOI: 10.3389/fped.2021.590969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/01/2021] [Indexed: 12/20/2022] Open
Abstract
Bacterial infections remain a major cause of morbidity and mortality in the neonatal period. Therefore, many neonates, including late preterm and term neonates, are exposed to antibiotics in the first weeks of life. Data on the importance of inter-individual differences and disease signatures are accumulating. Differences that may potentially influence treatment requirement and success rate. However, currently, many neonates are treated following a "one size fits all" approach, based on general protocols and standard antibiotic treatment regimens. Precision medicine has emerged in the last years and is perceived as a new, holistic, way of stratifying patients based on large-scale data including patient characteristics and disease specific features. Specific to sepsis, differences in disease susceptibility, disease severity, immune response and pharmacokinetics and -dynamics can be used for the development of treatment algorithms helping clinicians decide when and how to treat a specific patient or a specific subpopulation. In this review, we highlight the current and future developments that could allow transition to a more precise manner of antibiotic treatment in late preterm and term neonates, and propose a research agenda toward precision medicine for neonatal bacterial infections.
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Affiliation(s)
- Fleur M Keij
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Niek B Achten
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gerdien A Tramper-Stranders
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Franciscus Gasthuis and Vlietland, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Development and Regeneration, Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Annemarie M C van Rossum
- Division of Infectious Diseases, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - René F Kornelisse
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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18
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Härtel C, Faust K, Fortmann I, Humberg A, Pagel J, Haug C, Kühl R, Bohnhorst B, Pirr S, Viemann D, Simon A, Zemlin M, Poralla S, Müller A, Köstlin-Gille N, Gille C, Heckmann M, Rupp J, Herting E, Göpel W. Sepsis related mortality of extremely low gestational age newborns after the introduction of colonization screening for multi-drug resistant organisms. Antimicrob Resist Infect Control 2020; 9:144. [PMID: 32843080 PMCID: PMC7449086 DOI: 10.1186/s13756-020-00804-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/12/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In 2013 German infection surveillance guidelines recommended weekly colonization screening for multidrug-resistant (MDRO) or highly epidemic organisms for neonatal intensive care units (NICUs) and extended hygiene measures based on screening results. It remains a matter of debate whether screening is worth the effort. We therefore aimed to evaluate sepsis related outcomes before and after the guideline update. METHODS The German Neonatal Network (GNN) is a prospective cohort study including data from extremely preterm infants between 22 + 0 and 28 + 6 gestational weeks born in 62 German level III NICUs. RESULTS Infants treated after guideline update (n = 8.903) had a lower mortality (12.5% vs. 13.8%, p = 0.036), reduced rates for clinical sepsis (31.4 vs. 42.8%, p < 0.001) and culture-proven sepsis (14.4% vs. 16.5%, p = 0.003) as compared to infants treated before update (n = 3.920). In a multivariate logistic regression analysis, nine pathogens of culture-proven sepsis were associated with sepsis-related death, e.g. Pseudomonas aeruginosa [OR 59 (19-180), p < 0.001)]. However, the guideline update had no significant effect on pathogen-specific case fatality, total sepsis-related mortality and culture-proven sepsis rates with MDRO. While the exposure of GNN infants to cefotaxime declined over time (31.1 vs. 40.1%, p < 0.001), the treatment rate with meropenem was increased (31.6 vs. 26.3%, p < 0.001). CONCLUSIONS The introduction of weekly screening and extended hygiene measures is associated with reduced sepsis rates, but has no effects on sepsis-related mortality and sepsis with screening-relevant pathogens. The high exposure rate to meropenem should be a target of antibiotic stewardship programs.
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Affiliation(s)
- Christoph Härtel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany. .,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany. .,German Neonatal Network (GNN), Lübeck, Germany. .,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany. .,Department of Pediatrics, University of Würzburg, Josef-Schneider-Strasse 2, D-97080, Würzburg, Germany.
| | - Kirstin Faust
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Ingmar Fortmann
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Alexander Humberg
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Julia Pagel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany
| | - Clara Haug
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Reinhard Kühl
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, Diakonissenkrankenhaus, Flensburg, Germany
| | - Bettina Bohnhorst
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Sabine Pirr
- Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Dorothee Viemann
- Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Hannover Medical School, Hannover, Germany
| | - Arne Simon
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, Saar University Homburg, Homburg, Germany
| | - Michael Zemlin
- German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Pediatrics, Saar University Homburg, Homburg, Germany
| | - Silvia Poralla
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, University of Bonn, Bonn, Germany
| | - Andreas Müller
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Pediatrics, University of Bonn, Bonn, Germany
| | | | - Christian Gille
- German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany.,Department of Neonatology, Tuebingen University Children's Hospital, Tuebingen, Germany
| | - Matthias Heckmann
- German Neonatal Network (GNN), Lübeck, Germany.,Department of Neonatology and Pediatric Intensive Care, University of Greifswald, Greifswald, Germany
| | - Jan Rupp
- German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Lübeck, Germany.,Department of Infectious Diseases and Medical Microbiology, University of Lübeck, Lübeck, Germany
| | - Egbert Herting
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany.,German Neonatal Network (GNN), Lübeck, Germany.,Priming Immunity at the beginning of life (PRIMAL) Consortium, Lübeck, Germany
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19
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Schöndorf D, Simon A, Wagenpfeil G, Gärtner B, Geipel M, Zemlin M, Schöndorf M, Meyer S. Colonization Screening Targeting Multidrug-Resistant Gram-Negative Pathogens Does Not Increase the Use of Carbapenems in Very Low Birth Weight Infants. Front Pediatr 2020; 8:427. [PMID: 32850541 PMCID: PMC7423965 DOI: 10.3389/fped.2020.00427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/19/2020] [Indexed: 01/17/2023] Open
Abstract
Since 2012, a colonization screening (CoS) for multidrug-resistant Gram-negative bacteria (MRGN) in very low birth weight infants (VLWBI) was implemented in order to provide a basis for an effective empiric therapy of subsequent nosocomial infections (NI). According to antibiotic stewardship, carbapenems should be reserved for NI caused by MRGN or severe NI. We examined whether the CoS increased the first-line use of carbapenems. In this retrospective cohort analysis, we enrolled all VLBWI before (2009-2011) and after (2012-2014) the introduction of CoS (2012) at a tertiary university neonatal intensive care and neonatal intermediate care unit (NIMC) in Germany. Rectal swabs were used to detect MRGN colonization (on admission and weekly until discharge from the NIMC). The use of carbapenems was measured by days of therapy (DoT). To exclude the replacement of carbapenems by other antibiotics, antibiotic therapy for late-onset sepsis (LOS) was assessed by DoT and length of therapy (LoT). In 55/201 (27.4%) VLBWI, CoS detected MRGN colonization. Compared to the cohort prior to the introduction of CoS (n = 191), a significant decrease in LoT (p < 0.001) and total DoT (p < 0.001) was seen (n = 201). This was due to a significant decrease in LoT (p < 0.001) and total DoT (p < 0.001) in the birth weight category of 1,000-1,499 g. In these infants, DoT for carbapenems (p = 0.009) was significantly lower, possibly caused by a significant decline of LOS (25 episodes vs. 39 episodes, p = 0.025). Conversely, no significant differences in LoT and total DoT were seen in infants with a birth weight <500 g (p = 1.000; p = 0.758) and in infants weighing 500-999 g (p = 0.754; p = 0.794). DoT for carbapenems was not significantly different in the total cohort after the introduction of CoS (p = 0.341). Prolonged exposure to carbapenems (in terms of DoT) significantly postponed the first detection of MRGN colonization (p = 0.023). The introduction of CoS did not result in an increased use of carbapenems. Concomitant carbapenem treatment may reduce the sensitivity of CoS relying on rectal swabs.
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Affiliation(s)
- Dominik Schöndorf
- General Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Arne Simon
- Pediatric Oncology and Hematology, University Hospital of Saarland, Homburg, Germany
| | - Gudrun Wagenpfeil
- Theoretical Medicine, Institute for Medical Biometrics, Epidemiology and Medical Computer Sciences, University Hospital of Saarland, Homburg, Germany
| | - Barbara Gärtner
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, University Hospital of Saarland, Homburg, Germany
| | - Martina Geipel
- General Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Michael Zemlin
- General Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Marika Schöndorf
- Pediatric Oncology and Hematology, University Hospital of Saarland, Homburg, Germany
| | - Sascha Meyer
- General Pediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
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20
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Eichel V, Papan C, Boutin S, Pöschl J, Heeg K, Nurjadi D. Alteration of antibiotic regimen as an additional control measure in suspected multi-drug-resistant Enterobacter cloacae outbreak in a neonatal intensive care unit. J Hosp Infect 2019; 104:144-149. [PMID: 31525448 DOI: 10.1016/j.jhin.2019.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Increased occurrence of a particular species of Gram-negative bacteria (GNB), especially when multi-drug-resistant (MDR), in routine screening surveillance in neonatal intensive care units (NICUs) can be evoked by selection pressure. AIM To evaluate adaptation of the empiric antibiotic regimen for its usefulness as a control measure in suspected outbreaks in the NICU. METHODS In a retrospective outbreak analysis, cases between 1st December 2017 and 31st March 2018 were identified through microbiology and hygiene surveillance records. Furthermore, risk factors for MDR-GNB colonization were collected. Whole-genome sequencing (WGS) was performed on all isolates. Control measure documentations and interviews were employed to define interventions. As well as infection control measures, administration of third-generation cephalosporins was avoided and replaced whenever clinically acceptable as part of the intervention bundle. FINDINGS In total, nine patients were found to have rectal colonization with third-generation cephalosporin-resistant Enterobacter cloacae in routine screening surveillance in the pre-intervention period. After implementation of an infection control bundle, the incidence declined rapidly. WGS analysis revealed that two MDR E. cloacae were transmitted, and the majority were new cases. The incidence density of MDR-GNB colonization was 7.94/1000 patient-days (PD) before the intervention and 1.68/1000 PD during the altered antibiotic regimen. No infections with MDR-GNB occurred during the study. CONCLUSIONS Altering the antibiotic regimen with regard to selection pressure may be considered as part of an intervention bundle to rapidly control the emergence of MDR-GNB in suspected outbreak situations in the NICU.
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Affiliation(s)
- V Eichel
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany.
| | - C Papan
- Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - S Boutin
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
| | - J Pöschl
- Department of Neonatology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - K Heeg
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
| | - D Nurjadi
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Heidelberg, Germany
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Allegaert K, Flint R, Smits A. Pharmacokinetic modelling and Bayesian estimation-assisted decision tools to optimize vancomycin dosage in neonates: only one piece of the puzzle. Expert Opin Drug Metab Toxicol 2019; 15:735-749. [PMID: 31402708 DOI: 10.1080/17425255.2019.1655540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Vancomycin is commonly administered to neonates, while observational data on therapeutic drug monitoring (TDM, trough levels) suggest that vancomycin exposure and dosage remain substandard. Area covered: Data on vancomycin pharmacokinetics (PK) and its covariates are abundant. Consequently, modeling is an obvious tool to improve targeted exposure, with a shift from TDM trough levels to area under the curve (AUC24h) targets, as in adults. Continuous administration appeared as a practice to facilitate AUC24h target attainment, while Bayesian model-supported targeting emerged as a novel tool. However, the AUC24h/MIC (minimal inhibitory concentration) target itself should consider neonate-specific aspects (bloodstream infections, coagulase-negative staphylococci, protein binding, underexplored causes of variability, like assays, preparation and administration inaccuracies, or missing covariates). Expert opinion: To improve targeted exposure in neonates, initial vancomycin prescription should be based on 'a priori model-based individual dosing' using validated dosing regimens, followed by further tailoring by dosing optimization applying Bayesian estimation-assisted TDM. Future research should focus on the feasibility to integrate these tools (individualized dosing, Bayesian models) in clinical practice, and to perform PK/PD studies in the relevant animal models and human neonatal setting (coagulase-negative staphylococci, bloodstream infections).
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Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Development and Regeneration, KU Leuven , Leuven , Belgium
| | - Robert Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Pharmacy, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven , Leuven , Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven , Leuven , Belgium
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Rational Use of Antibiotics in Neonates: Still in Search of Tailored Tools. Healthcare (Basel) 2019; 7:healthcare7010028. [PMID: 30781454 PMCID: PMC6473895 DOI: 10.3390/healthcare7010028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 01/31/2019] [Accepted: 02/14/2019] [Indexed: 12/13/2022] Open
Abstract
Rational medicine use in neonates implies the prescription and administration of age-appropriate drug formulations, selecting the most efficacious and safe dose, all based on accurate information on the drug and its indications in neonates. This review illustrates that important uncertainties still exist concerning the different aspects (when, what, how) of rational antibiotic use in neonates. Decisions when to prescribe antibiotics are still not based on robust decision tools. Choices (what) on empiric antibiotic regimens should depend on the anticipated pathogens, and the available information on the efficacy and safety of these drugs. Major progress has been made on how (beta-lactam antibiotics, aminoglycosides, vancomycin, route and duration) to dose. Progress to improve rational antibiotic use necessitates further understanding of neonatal pharmacology (short- and long-term safety, pharmacokinetics, duration and route) and the use of tailored tools and smarter practices (biomarkers, screening for colonization, and advanced therapeutic drug monitoring techniques). Implementation strategies should not only facilitate access to knowledge and guidelines, but should also consider the most effective strategies (‘skills’) and psychosocial aspects involved in the prescription process: we should be aware that both the decision not to prescribe as well as the decision to prescribe antibiotics is associated with risks and benefits.
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