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Raturi A, Chandran S. Neonatal Sepsis: Aetiology, Pathophysiology, Diagnostic Advances and Management Strategies. Clin Med Insights Pediatr 2024; 18:11795565241281337. [PMID: 39371316 PMCID: PMC11452898 DOI: 10.1177/11795565241281337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 08/21/2024] [Indexed: 10/08/2024] Open
Abstract
Neonatal sepsis, a bloodstream infection in the first 28 days of life, is a leading cause of morbidity and mortality among infants in both developing and developed countries. Additionally, sepsis is distinguished in neonates by unique pathophysiological and presentational factors relating to its development in immature neonatal immune systems. This review focuses on the current understanding of the mechanics and implications of neonatal sepsis, providing a comprehensive overview of the epidemiology, aetiology, pathophysiology, major risk factors, signs and symptoms and recent consensus on the diagnosis and management of both early-onset and late-onset neonatal sepsis. It also includes a discussion on novel biomarkers and upcoming treatment strategies for the condition as well as the potential of COVID-19 infection to progress to sepsis in infants.
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Affiliation(s)
- Adi Raturi
- University of Glasgow School of Medicine, Glasgow, UK
| | - Suresh Chandran
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
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Abu Shqara R, Nakhleh Francis Y, Lowenstein L, Frank Wolf M. The relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes: a retrospective cohort study. Am J Obstet Gynecol 2024; 231:361.e1-361.e10. [PMID: 38871240 DOI: 10.1016/j.ajog.2024.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial. OBJECTIVE This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature. STUDY DESIGN This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm2), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g. RESULTS This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission. CONCLUSION In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.
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Affiliation(s)
- Raneen Abu Shqara
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Yara Nakhleh Francis
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Maya Frank Wolf
- Raya Strauss Wing of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
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Butler EA, Grandi SM, Matai L, Wang X, Cohen E, Ray JG. Differences in maternal-newborn ABO blood groups and risk of serious infant infection. QJM 2024; 117:512-519. [PMID: 38402542 PMCID: PMC11290255 DOI: 10.1093/qjmed/hcae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/11/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND During pregnancy, various maternal IgG antibodies are transferred to the developing fetus, some of which may protect the newborn against infection. If a mother and her fetus have different A, B or O (ABO) blood groups, then transferred maternal antibodies may plausibly protect the infant against infection. AIM To determine if maternal-newborn ABO blood group incongruence vs. congruence is associated with a lower risk of serious infection in the infant. DESIGN Retrospective population-based cohort. METHODS We used linked patient-level datasets for all singleton hospital livebirths from 2008 to 2022 in Ontario, Canada, with known maternal and newborn ABO blood groups. We used a dichotomous exposure state, either ABO blood group congruent (N = 114 507) or incongruent (N = 43 074). The main outcome of interest was the risk of serious infant infection within 27 days, and from 28 to 365 days, after birth. Cox proportional hazard models generated hazard ratios and 95% confidence intervals, and were adjusted for maternal age, world region of origin, residential income quintile and gestational age at birth. RESULTS Relative to maternal-newborn congruency, incongruent ABO blood group was associated with an adjusted hazard ratio of 0.88 (95% CI: 0.80-0.97) for serious neonatal infection within 27 days of birth, and 0.93 (95% CI: 0.90-0.96) for serious infection between 28 and 365 days after birth. CONCLUSIONS Maternal-newborn ABO incongruence may be associated with a lower relative risk of a serious infant infection within 27 days, and from 28 to 365 days, after birth.
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Affiliation(s)
- E A Butler
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - S M Grandi
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - X Wang
- ICES, Toronto, ON, Canada
| | - E Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - J G Ray
- ICES, Toronto, ON, Canada
- Department of Medicine, St Michael’s Hospital, Toronto, ON, Canada
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Liang CS, Sebastian A, McKennan C, Bertoni CB, Hooven TA, Kish M, Schwabenbauer K, Yanowitz T, King BC. Clinical and economic impacts of a modified-observational screening approach to well-appearing infants born to mothers with chorioamnionitis. J Perinatol 2024; 44:1042-1049. [PMID: 38155229 DOI: 10.1038/s41372-023-01858-3] [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: 09/07/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Term infants born to mothers with chorioamnionitis are at risk for early-onset sepsis (EOS). We aimed to measure the impact of changing from a categorical to a modified-observational EOS screening approach on NICU admission, antibiotic utilization, and hospitalization costs. STUDY DESIGN Single-center retrospective pre-post cohort study of full-term infants born to mothers with chorioamnionitis. Primary outcomes included NICU admission, antibiotic utilization, and hospitalization costs. Outcomes were adjusted for demographic variables. Budget-impact analysis was performed using bootstrapping with replication. RESULTS 380 term infants were included (197 categorical; 183 modified-observational). There was a significant decrease in NICU admission and antibiotic utilization (p < 0.05) in the modified-observational cohort but no significant difference in per-patient total hospitalization costs. Budget-impact analysis suggested a high probability of cost savings. CONCLUSION A modified-observational approach to evaluating term infants of mothers with chorioamnionitis can reduce NICU admission and unnecessary antibiotic therapy, and may lead to cost-savings.
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Affiliation(s)
- Cynthia S Liang
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA.
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA.
| | - Armand Sebastian
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Christopher McKennan
- University of Pittsburgh, School of Arts and Sciences, Department of Statistics, Pittsburgh, PA, USA
| | - C Briana Bertoni
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Thomas A Hooven
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh Richard King Mellon Institute for Pediatric Research, Pittsburgh, PA, USA
| | - Mary Kish
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Kathleen Schwabenbauer
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Toby Yanowitz
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
| | - Brian C King
- University of Pittsburgh, School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC Magee-Womens Hospital, Pittsburgh, PA, USA
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Alhindi MY, Almalki FG, Al Saif S, Almalahi A, Alsaegh MH, Mustafa A, AlQurashi MA. Evaluating a Modified Use of the Kaiser Permanente Early-onset Sepsis Risk Calculator to Reduce Antibiotic Exposure: a Retrospective Study. BMJ Paediatr Open 2024; 8:e002597. [PMID: 38844386 PMCID: PMC11163676 DOI: 10.1136/bmjpo-2024-002597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/12/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Early-onset neonatal sepsis (EONS) remains an important disease entity due to very serious adverse outcomes if left untreated. Lack of diagnostic tools in identifying healthy from diseased neonates, and clinicians' fear of the missing positive-culture sepsis babies, or babies with clinical sepsis have led to overtreating and unnecessary antibiotic exposure. Kaiser Permanente EONS risk calculator is an internally validated tool that can predict EONS. This sepsis risk calculator (SRC) classifies neonates into three subgroups: (1) ill-appearing, (2) equivocal and (3) well-appearing. We propose a modification to this tool that aims to use it solely for well-appearing babies. This modification represents a more conservative approach to decrease antibiotic exposure and offers an alternative for those hesitant to fully implement this tool. METHODS This is a dual-centre retrospective study where data were extracted from the electronic medical records. Our primary outcome was to validate the modified use of the SRC with a two-by-two table. Specificity, negative predictive value and expected antibiotic reduction were used to evaluate the tool's feasibility. RESULT Among 770 babies suspected of EONS, the feasibility of the modified use was tested. The expected antibiotic exposure reduction rate on the modification was 40.4% overall. The proposed modification resulted in a specificity and negative predictive value of 99.28% (95% CI: 97.92% to 99.85%) and 99.5% (95% CI: 99% to 99.8%), respectively. CONCLUSION The modified use of the sepsis risk calculator has shown that it can safely reduce antibiotic exposure in well-appearing babies. The modified use is used as a 'rule out' test that can identify very low risk of EONS babies, and safely minimise antibiotic exposure. Further prospective studies are needed to examine the efficacy of this use, and quality improvement projects are required to evaluate its applicability in different clinical settings.
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Affiliation(s)
- Mohammed Yasir Alhindi
- Neonatology Division, Department of Pediatrics, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia
| | - Faisal Ghazi Almalki
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
| | - Saif Al Saif
- Neonatal Intensive Care Department, Women's Health Specialized Hospital, Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Abdulaziz Almalahi
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
| | - Mawaddah Hesham Alsaegh
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
| | - Ahmed Mustafa
- Neonatology Division, Department of Pediatrics, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
| | - Mansour Abdullah AlQurashi
- Neonatology Division, Department of Pediatrics, King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Jeddah, Saudi Arabia
- Department of Basic Medical Sciences, College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah, Saudi Arabia
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Yew R, Macaskill L, Brown S, Dixie M, Dogar D, Checketts E, Surana P. Impact of adopting a neonatal sepsis risk calculator in a diverse population in Birmingham, UK. Arch Dis Child Fetal Neonatal Ed 2024; 109:227-228. [PMID: 37607807 DOI: 10.1136/archdischild-2023-325883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Rachel Yew
- Neonatal Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Laura Macaskill
- Neonatal Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sebastian Brown
- PRAM, Paediatric Research Across the Midlands, West Midlands, UK
| | - Michael Dixie
- Neonatal Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Daniel Dogar
- Neonatal Unit, Good Hope Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Checketts
- Neonatal Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pinki Surana
- Neonatal Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Shah NM, Charani E, Ming D, Cheah FC, Johnson MR. Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:46-61. [PMID: 38263965 PMCID: PMC10800776 DOI: 10.1016/j.jointm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 01/25/2024]
Abstract
Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.
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Affiliation(s)
- Nishel M Shah
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Damien Ming
- Department of Infectious Diseases, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
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Abu Shqara R, Glikman D, Jad S, Rechnitzer H, Lowenstein L, Frank Wolf M. Antibiotic treatment of women with isolated intrapartum fever vs clinical chorioamnionitis: maternal and neonatal outcomes. Am J Obstet Gynecol 2023; 229:540.e1-540.e9. [PMID: 38051599 DOI: 10.1016/j.ajog.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Clinical chorioamnionitis refers to the presence of maternal fever (≥38°C) and at least 2 clinical signs: (1) maternal tachycardia (>100 bpm), (2) fetal tachycardia (>160 bpm), (3) maternal leukocytosis >15,000/mm2, (4) purulent vaginal discharge, and (5) uterine tenderness. Few data exist to guide the appropriate management of women with isolated intrapartum fever in the absence of other clinical signs suggesting chorioamnionitis. OBJECTIVE This study compared maternal and neonatal infectious outcomes and microbiological outcomes between women with isolated intrapartum fever and women with clinical chorioamnionitis. STUDY DESIGN This 10-year retrospective study included all the laboring women at our institution, at ≥34 weeks of gestation, with a singleton pregnancy and body temperature of ≥38.0°C, with or without other evidences of infection. According to our department protocol, women with isolated intrapartum fever received intravenous ampicillin, whereas women with clinical chorioamnionitis received intravenous ampicillin plus gentamicin. The primary outcome was puerperal endometritis, compared between women with isolated intrapartum fever (treated with ampicillin) and women with clinical chorioamnionitis (treated with ampicillin plus gentamicin). The secondary maternal outcomes consisted of (1) maternal clinical outcomes, such as cesarean delivery, surgical site infection, postpartum hemorrhage, and postpartum length of stay, and (2) microbiological studies, including positive chorioamniotic membrane swabs and blood culture. Among the secondary neonatal outcomes were early-onset sepsis, neonatal intensive care unit admission, and length of stay. Of note, 2 multivariate logistic regression models were created. A model aimed to predict puerperal endometritis controlled for gestational age of >41 weeks, diabetes mellitus, obesity, positive group B streptococcus status, rupture of membrane ≥18 hours, meconium staining, positive chorioamniotic membrane swabs, cesarean delivery, and empiric postdelivery antibiotic administration. A model aimed to predict neonatal early-onset sepsis controlled for gestational age of 34 to 37 weeks, positive group B streptococcus status, rupture of membrane ≥18 hours, and positive chorioamniotic membrane swabs. RESULTS Overall, 458 women met the inclusion criteria. Compared with women with clinical chorioamnionitis (n=231), women with isolated intrapartum fever (n=227) had higher rates of puerperal endometritis (3.9% vs 8.8%; P=.03), early-onset sepsis (0.4% vs 4.4%; P=.005), positive chorioamniotic membrane swabs (46.3% vs 63.9%; P<.001), and ampicillin-resistant Escherichia coli (35.5% vs 48.9%; P=.033). The rate of group B streptococcus-positive chorioamniotic membrane swabs was similar between the groups. In a subanalysis of women with negative or unknown group B streptococcus status, the puerperal endometritis and neonatal early-onset sepsis rates were higher among women with isolated intrapartum fever than women with suspected chorioamnionitis (8.7% vs 3.3% [P=.041] and 4.1% vs 0% [P<.001], respectively). In 2 multivariate analysis models, among women with isolated intrapartum fever treated with ampicillin compared with those with clinical chorioamnionitis treated with ampicillin and gentamicin, the odds ratio of antibiotic treatment of endometritis was 2.65 (95% confidence interval, 1.06-6.62; P=.036), and the odds ratio of neonatal early-onset sepsis was 8.33 (95% confidence interval, 1.04-60.60; P=.045). CONCLUSION Women with intrapartum fever, with or without other signs of infection, were at increased risk of maternal and neonatal complications. The use of ampicillin as a sole agent in isolated intrapartum fever might promote ampicillin-resistant E coli growth in the chorioamniotic membranes and consequently lead to puerperal endometritis and early-onset sepsis. In this context, a broad-range antibiotic should be considered.
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Affiliation(s)
- Raneen Abu Shqara
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Daniel Glikman
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Saher Jad
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Hagai Rechnitzer
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Maya Frank Wolf
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
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van Veen LEJ, van der Weijden BM, van Bodegom-Vos L, Hol J, Visser DH, Achten NB, Plötz FB. Barriers and Facilitators to the Implementation of the Early-Onset Sepsis Calculator: A Multicenter Survey Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1682. [PMID: 37892345 PMCID: PMC10605684 DOI: 10.3390/children10101682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Prior studies demonstrated the neonatal early-onset sepsis (EOS) calculator's potential in drastically reducing antibiotic prescriptions, and its international adoption is increasing rapidly. To optimize the EOS calculator's impact, successful implementation is crucial. This study aimed to identify key barriers and facilitators to inform an implementation strategy. A multicenter cross-sectional survey was carried out among physicians, residents, nurses and clinical obstetricians of thirteen Dutch hospitals. Survey development was prepared through a literature search and stakeholder interviews. Data collection and analysis were based on the Consolidated Framework for Implementation Research (CFIR). A total of 465 stakeholders completed the survey. The main barriers concerned the expectance of the department's capacity problems and the issues with maternal information transfer between departments. Facilitators concerned multiple relative advantages of the EOS calculator, including stakeholder education, EOS calculator integration in the electronic health record and existing positive expectations about the safety and effectivity of the calculator. Based on these findings, tailored implementation interventions can be developed, such as identifying early adopters and champions, conducting educational meetings tailored to the target group, creating ready-to-use educational materials, integrating the EOS calculator into electronic health records, creating a culture of collective responsibility among departments and collecting data to evaluate implementation success and innovation results.
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Affiliation(s)
- Liesanne E. J. van Veen
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Department of Paediatrics, Franciscus Gasthuis en Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
- Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands;
| | - Bo M. van der Weijden
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Jeroen Hol
- Department of Paediatrics, Noord West Ziekenhuis, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands;
| | - Douwe H. Visser
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam UMC, Department of Neonatology, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Niek B. Achten
- Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands;
| | - Frans B. Plötz
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands; (L.E.J.v.V.); (B.M.v.d.W.)
- Amsterdam UMC, Department of Paediatrics and Amsterdam Reproduction & Development Research Institute, Location University of Amsterdam, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
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Paraparambil Vellamgot A, Salameh K, AlBedaywi RR, Alhoyed SM, Habboub LH, Abdellatif W, Daoud OA, Atrash M, Zakaria A. Kaiser Permanente early-onset sepsis calculator as a safe tool for reducing antibiotic use among chorioamnionitis-exposed term neonates: Qatar experience. BMJ Open Qual 2023; 12:e002459. [PMID: 37827729 PMCID: PMC10582875 DOI: 10.1136/bmjoq-2023-002459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023] Open
Abstract
Being an important cause of early-onset neonatal sepsis, clinical chorioamnionitis in the mother results in frequent laboratory workup and antibiotic use for the neonate. Neonatal intensive care units (NICUs) in Qatar follow the categorical approach recommended by the Centers for Disease Control and Prevention, USA, and all chorioamnionitis-exposed neonates receive antibiotics.Our project aimed to reduce antibiotic use among chorioamnionitis-exposed, asymptomatic term babies by adopting the early-onset sepsis calculator (EOSCAL). Reduction of blood culture and NICU stay duration were added as secondary objectives later.The Institute of Healthcare Improvement Model of Improvement was used. Antibiotic use rate was the primary outcome measure. Blood culture rate and early transfer to the postnatal ward were added after 1 year. The process measures included the EOSCAL use rate and calculation error rate. The rate of positive culture among untreated babies within the first week was taken as a balancing measure. Monthly data were collected from February 2020 and entered as run charts. Calculation errors were dealt by multiple PDSAs. Additional outcome measures were added in January 2021. Data collection and monitoring continued till December 2022.Among 3837 inborn NICU admissions, 464 (12 %) were chorioamnionitis-exposed babies. Of them, 341 (74%) cases were eligible for inclusion. Among eligible cases, 270 (79%) did not receive antibiotics. Blood culture could be avoided among 106 (97% of low-risk babies) and NICU stay was reduced among 45 (92% of eligible low-risk babies). None of the untreated babies developed sepsis during the first week.Implementation of this project effectively and safely reduced the antibiotic use and blood culture rate among term, well-appearing babies exposed to chorioamnionitis. The project resulted in enhanced patient safety, experience and flow and reduced cost. It is recommendable to other NICU settings in Qatar.
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Affiliation(s)
| | - Khalil Salameh
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | | | | | - Muna Atrash
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
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Nath S, Alissa R, Shukla S, Li M, Smotherman C, Hudak ML. Tailored Approach to Evaluation and Management of Early Onset Neonatal Sepsis in a Safety-Net Teaching Hospital in Northeast Florida. Cureus 2023; 15:e45263. [PMID: 37846280 PMCID: PMC10576972 DOI: 10.7759/cureus.45263] [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: 03/30/2023] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
Objective Early onset neonatal sepsis (EONS) remains a significant cause of morbidity and mortality in newborns in the immediate postnatal period. High empiric antibiotic use in well-appearing infants with known risk factors for sepsis led the American Academy of Pediatrics (AAP) to revise its 2010 guidelines for the evaluation and management of EONS to avoid overuse of antibiotics. In this recent clinical report, the AAP provided a framework that outlined several evidence-based approaches for sepsis risk assessment in newborns that can be adopted by institutions based on local resources and structure. One of these approaches, the sepsis risk calculator (SRC) developed by Kaiser Permanente, has been widely validated for reducing unnecessary antibiotic exposure and blood work in infants suspected of having EONS. In order to determine the utility and safety of modifying our institution's protocol to the SRC, we implemented a two-phased approach to evaluate the use of SRC in our newborn nursery. Phase 1 utilized a retrospective review of cases with SRC superimposition. If results from Phase 1 were found to be favorable, Phase 2 initiated a trial of the SRC for a six-month period prior to complete implementation. Methods Phase 1 consisted of retrospectively applying the SRC to electronic medical records (EMR) of infants ≥ 35 weeks' gestational age admitted to the newborn nursery with risk factors for EONS between June 2016 and May 2017. We compared actual antibiotic use as determined by the unit's EONS protocol for evaluation and management based on 2010 Centers for Disease Control and Prevention (CDC) and AAP guidelines to SRC-recommended antibiotic use. We used EMR to determine maternal and infant data, blood work results, and antibiotic usage as well as used daily progress notes by the clinical team to determine the clinical status of the infants retrospectively. Based on the projected reduction in blood work and antibiotics use with the retrospective superimposition of SRC on this cohort of infants and identification of our high-risk patient subset, we developed a novel, hybrid EONS protocol that we implemented and assessed throughout Phase 2, a six-month period from August 2018 to January 2019, as a prospective observational study. Results Phase 1 (SRC superimposition) demonstrated that the use of the SRC would have reduced empiric antibiotic use from 56% to 13% in the study cohort when compared with 2010 CDC/AAP guidelines. However, these same findings revealed use of the SRC would have resulted in delayed evaluation and initiation of antibiotics in 2 of 4 chorioamnionitis-exposed infants with positive blood cultures. During Phase 2 (n=302), with the implementation of our tailored approach (SRC implementation with additional blood culture in chorioamnionitis-exposed infants), 12 (4%) neonates received empiric antibiotic treatment compared to nine (3%) neonates who would have been treated per strict adherence to SRC recommendations. No neonate had culture-positive EONS. Continued use of 2010 CDC/AAP guidelines would have led to empiric antibiotic use in 38 (12.6%) infants in this cohort. Conclusion We developed a novel hybrid approach to the evaluation and management of neonates at increased risk of EONS by tailoring SRC recommendations to our safety-net population. Our stewardship effort achieved a safe and significant reduction in antibiotic usage compared to prior usage determined using CDC/AAP guidelines.
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Affiliation(s)
- Sfurti Nath
- Pediatrics/Neonatal Perinatal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Rana Alissa
- Pediatrics, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | | | - Meng Li
- Pediatrics, Pediatric First, Warner Robins, USA
| | - Carmen Smotherman
- Pathology/Biostatistics, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
| | - Mark L Hudak
- Pediatrics/Neonatal Perinatal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, USA
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12
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Neal SR, Fitzgerald F, Chimhuya S, Heys M, Cortina-Borja M, Chimhini G. Diagnosing early-onset neonatal sepsis in low-resource settings: development of a multivariable prediction model. Arch Dis Child 2023; 108:608-615. [PMID: 37105710 PMCID: PMC10423484 DOI: 10.1136/archdischild-2022-325158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/26/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To develop a clinical prediction model to diagnose neonatal sepsis in low-resource settings. DESIGN Secondary analysis of data collected by the Neotree digital health system from 1 February 2019 to 31 March 2020. We used multivariable logistic regression with candidate predictors identified from expert opinion and literature review. Missing data were imputed using multivariate imputation and model performance was evaluated in the derivation cohort. SETTING A tertiary neonatal unit at Sally Mugabe Central Hospital, Zimbabwe. PATIENTS We included 2628 neonates aged <72 hours, gestation ≥32+0 weeks and birth weight ≥1500 g. INTERVENTIONS Participants received standard care as no specific interventions were dictated by the study protocol. MAIN OUTCOME MEASURES Clinical early-onset neonatal sepsis (within the first 72 hours of life), defined by the treating consultant neonatologist. RESULTS Clinical early-onset sepsis was diagnosed in 297 neonates (11%). The optimal model included eight predictors: maternal fever, offensive liquor, prolonged rupture of membranes, neonatal temperature, respiratory rate, activity, chest retractions and grunting. Receiver operating characteristic analysis gave an area under the curve of 0.74 (95% CI 0.70-0.77). For a sensitivity of 95% (92%-97%), corresponding specificity was 11% (10%-13%), positive predictive value 12% (11%-13%), negative predictive value 95% (92%-97%), positive likelihood ratio 1.1 (95% CI 1.0-1.1) and negative likelihood ratio 0.4 (95% CI 0.3-0.6). CONCLUSIONS Our clinical prediction model achieved high sensitivity with low specificity, suggesting it may be suited to excluding early-onset sepsis. Future work will validate and update this model before considering implementation within the Neotree.
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Affiliation(s)
- Samuel R Neal
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Felicity Fitzgerald
- Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Simba Chimhuya
- Child and Adolescent Health Unit, University of Zimbabwe, Harare, Zimbabwe
| | - Michelle Heys
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Mario Cortina-Borja
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
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Piyasena C, Galu S, Yoshida R, Thakkar D, O'Sullivan J, Longley C, Evans K, Sweeney S, Kendall G, Ben-Sasi K, Richards J, Harris C, Jagodzinski J, Demirjian A, Lamagni T, Le Doare K, Heath PT, Battersby C. Comparison of diagnoses of early-onset sepsis associated with use of Sepsis Risk Calculator versus NICE CG149: a prospective, population-wide cohort study in London, UK, 2020-2021. BMJ Open 2023; 13:e072708. [PMID: 37500270 PMCID: PMC10387649 DOI: 10.1136/bmjopen-2023-072708] [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] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE We sought to compare the incidence of early-onset sepsis (EOS) in infants ≥34 weeks' gestation identified >24 hours after birth, in hospitals using the Kaiser Permanente Sepsis Risk Calculator (SRC) with hospitals using the National Institute for Health and Care Excellence (NICE) guidance. DESIGN AND SETTING Prospective observational population-wide cohort study involving all 26 hospitals with neonatal units colocated with maternity services across London (10 using SRC, 16 using NICE). PARTICIPANTS All live births ≥34 weeks' gestation between September 2020 and August 2021. OUTCOME MEASURES EOS was defined as isolation of a bacterial pathogen in the blood or cerebrospinal fluid (CSF) culture from birth to 7 days of age. We evaluated the incidence of EOS identified by culture obtained >24 hours to 7 days after birth. We also evaluated the rate empiric antibiotics were commenced >24 hours to 7 days after birth, for a duration of ≥5 days, with negative blood or CSF cultures. RESULTS Of 99 683 live births, 42 952 (43%) were born in SRC hospitals and 56 731 (57%) in NICE hospitals. The overall incidence of EOS (<72 hours) was 0.64/1000 live births. The incidence of EOS identified >24 hours was 2.3/100 000 (n=1) for SRC vs 7.1/100 000 (n=4) for NICE (OR 0.5, 95% CI (0.1 to 2.7)). This corresponded to (1/20) 5% (SRC) vs (4/45) 8.9% (NICE) of EOS cases (χ=0.3, p=0.59). Empiric antibiotics were commenced >24 hours to 7 days after birth in 4.4/1000 (n=187) for SRC vs 2.9/1000 (n=158) for NICE (OR 1.5, 95% CI (1.2 to 1.9)). 3111 (7%) infants received antibiotics in the first 24 hours in SRC hospitals vs 8428 (15%) in NICE hospitals. CONCLUSION There was no significant difference in the incidence of EOS identified >24 hours after birth between SRC and NICE hospitals. SRC use was associated with 50% fewer infants receiving antibiotics in the first 24 hours of life.
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Affiliation(s)
| | - Sorana Galu
- Homerton University Hospital NHS Foundation Trust, London, UK
| | - Rie Yoshida
- Imperial College Healthcare NHS Trust, London, UK
| | - Devangi Thakkar
- The Hillingdon University Hospitals NHS Foundation Trust, Harrow, London, UK
| | - Joanna O'Sullivan
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, London, UK
| | | | - Katie Evans
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Giles Kendall
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Chris Harris
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Alicia Demirjian
- Evelina London Children's Hospital, London, UK
- United Kingdom Health Security Agency, London, UK
| | | | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Paul T Heath
- Centre for Neonatal and Paediatric Infection, St George's University of London, London, UK
| | - Cheryl Battersby
- Neonatal Medicine, School of Public Health, Imperial College London Faculty of Medicine, London, UK
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Levi M, Melamed R, Shany E, Marks K, Landau D, Shashar S, Golan A. The impact of the early onset neonatal sepsis calculator on antibiotic initiation: a single center study in Israel. Eur J Pediatr 2023:10.1007/s00431-023-04993-3. [PMID: 37119298 DOI: 10.1007/s00431-023-04993-3] [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: 12/19/2022] [Revised: 04/13/2023] [Accepted: 04/19/2023] [Indexed: 05/01/2023]
Abstract
To evaluate the effect of implementation of the Kaiser Permanente (KP) early onset sepsis (EOS) calculator in infants born at 34 week's gestation or more on antibiotic utilization and length of hospitalization. A single center, retrospective cohort study included all neonates born in Soroka Medical Center at 34 weeks gestation or more between January 1st, 2015, and January 1st, 2019, with a predefined maternal risk factor for EOS. Two cohorts of neonates were compared during two time periods, before and after the implementation of the KP calculator. Multivariable logistic and linear regressions were performed to assess the effect of the KP calculator on antibiotic treatment and length of hospitalization. Also, an interrupted time series (ITS) analysis was used to assess the time trends of the two periods. The study included 3858 neonates in the pre-implementation period and 3081 neonates in the post-implementation cohort. The use of the calculator resulted in a significant reduction (46%) in antibiotics treatment for suspected EOS (5.1 vs. 9.4%, P < 0.001). The ITS analysis demonstrated a sharp decline in the slope of antibiotic treatment in the post intervention period: (b = -0.14, p-value = 0.08). The length of hospitalization was significantly reduced in the post-implementation cohort from 62 to 60 h (p-value < 0.001) with no clinical significance. The incidence of EOS was similar in both groups. Conclusion: A significant reduction in antibiotic treatment was demonstrated after the implementation of the KP calculator without an increase incidence of EOS. The calculator is a powerful accessory decision-making tool that can be used safely in combination with, but not replacing, thorough clinical assessment. What is Known: • The EOS calculator is a useful tool that leads to a significant reduction in preemptive antibiotic utilization. What is New: • The EOS calculator is sensitive when applied to the whole-nursery. • The calculator is useful in different populations, also when women are not routinely screened for GBS.
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Affiliation(s)
- Mor Levi
- Ben-Gurion University of the Negev, Beer Sheva, Israel.
| | - Rimma Melamed
- Department of Pediatrics, Infectious Disease Unit, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Eilon Shany
- Department of Neonatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Kyla Marks
- Department of Neonatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Danielle Landau
- Department of Neonatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Agneta Golan
- Department of Neonatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Schlapbach LJ, Carrol ED. Reducing Antibiotic Exposure at the Beginning of Life. JAMA Netw Open 2022; 5:e2243705. [PMID: 36416827 DOI: 10.1001/jamanetworkopen.2022.43705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
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Abstract
Clinical Decision Support (CDS) tools help the healthcare team diagnose, monitor, and treat patients more efficiently and consistently by executing clinical practice guidelines and recommendations. As a result, CDS has a direct impact on the delivery and healthcare outcomes. This review covers the fundamental concepts, as well as the infrastructure needed to create a CDS tool and examples of its use in the neonatal setting. This article also serves as a primer on what to think about when proposing the development of a new CDS tool, or when upgrading an existing one. We also highlight important elements that influence CDS development, such as informatics methodologies, data and device interoperability, and regulation.
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Affiliation(s)
- Anoop Rao
- Stanford University School of Medicine, Center for Academic Medicine, # 434A, 453 Quarry Rd, Palo Alto, CA, 94304, USA.
| | - Jonathan Palma
- Orlando Health Winnie Palmer Hospital for Women and Babies, 83 W Miller St, Orlando, FL, 32806, USA.
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17
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Fernandes M, Winckworth L, Lee L, Akram M, Struthers S. Screening for early-onset neonatal sepsis on the Kaiser Permanente sepsis risk calculator could reduce neonatal antibiotic usage by two-thirds. Pediatr Investig 2022; 6:171-178. [PMID: 36203516 PMCID: PMC9523803 DOI: 10.1002/ped4.12344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Effective screening strategies for early-onset neonatal sepsis (EONS) have the potential to reduce high volume parenteral antibiotics (PAb) usage in neonates. Objective To compare management decisions for EONS, between CG149 National Institute for Health and Care Excellence (NICE) guidelines and those projected through the virtual application of the Kaiser Permanente sepsis risk calculator (SRC) in a level 2 neonatal unit at a district general hospital (DGH). Methods Hospital records were reviewed for maternal and neonatal risk factors for EONS, neonatal clinical examination findings, and microbial culture results for all neonates born at ≥34 weeks' gestation between February and July 2019, who were (1) managed according to CG149-NICE guidelines or (2) received PAb within 72 h following birth at a DGH in Winchester, UK. SRC projections were obtained using its virtual risk estimator. Results Sixty infants received PAb within the first 72 h of birth during the study period. Of these, 19 (31.7%) met SRC criteria for antibiotics; 20 (33.3%) met the criteria for enhanced observations and none had culture-proven sepsis. Based on SRC projections, neonates with '≥1 NICE clinical indicator and ≥1 risk factor' were most likely to have a sepsis risk score (SRS) >3. Birth below 37 weeks' gestation (risk ratio [RR] = 2.31, 95% confidence interval [CI]: 1.02-5.22) and prolonged rupture of membranes (RR = 3.14, 95% CI: 1.16-8.48) increased the risk of an SRS >3. Interpretation Screening for EONS on the SRC could potentially reduce PAb usage by 68% in term and near-term neonates in level 2 neonatal units.
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Affiliation(s)
- Michelle Fernandes
- The Department of Neonatal Medicine and the Neonatal Intensive Care Unit, Princess Anne HospitalUniversity Hospitals Southampton NHS Foundation TrustSouthamptonUK
- The MRC Lifecourse Epidemiology Centre and Human Development and Health Academic Unit, Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Nuffield Department of Women's and Reproductive Health, John Radcliffe HospitalUniversity of OxfordOxfordUK
| | | | - Lyrille Lee
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
| | - Madiha Akram
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
| | - Simon Struthers
- Department of PediatricsRoyal Hampshire County HospitalWinchesterUK
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Neonatal Early Onset Sepsis (EOS) Calculator plus Universal Serial Physical Examination (SPE): A Prospective Two-Step Implementation of a Neonatal EOS Prevention Protocol for Reduction of Sepsis Workup and Antibiotic Treatment. Antibiotics (Basel) 2022; 11:antibiotics11081089. [PMID: 36009958 PMCID: PMC9405114 DOI: 10.3390/antibiotics11081089] [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: 07/10/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Current neonatal early-onset sepsis (EOS) guidelines lack consensus. Recent studies suggest three different options for EOS risk assessment among infants born ≥35 wks gestational age (GA), leading to different behaviors in the sepsis workup and antibiotic administration. A broad disparity in clinical practice is found in Neonatal Units, with a large number of non-infected newborns evaluated and treated for EOS. Broad spectrum antibiotics in early life may induce different short- and long-term adverse effects, longer hospitalization, and early mother-child separation. In this single-center prospective study, a total of 3002 neonates born in three periods between 2016 and 2020 were studied, and three different workup algorithms were compared: the first one was based on the categorical risk assessment; the second one was based on a Serial Physical Examination (SPE) strategy for infants with EOS risk factors; the third one associated an informatic tool (Neonatal EOS calculator) with a universal extension of the SPE strategy. The main objective of this study was to reduce the number of neonatal sepsis workups and the rate of antibiotic administration and favor rooming-in and mother−infant bonding without increasing the risk of sepsis and mortality. The combined strategy of universal SPE with the EOS Calculator showed a significant reduction of laboratory tests (from 33% to 6.6%; p < 0.01) and antibiotic treatments (from 8.5% to 1.4%; p < 0.01) in term and near-term newborns. EOS and mortality did not change significantly during the study period.
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Salsabila K, Toha NMA, Rundjan L, Pattanittum P, Sirikarn P, Rohsiswatmo R, Wandita S, Hakimi M, Lumbiganon P, Green S, Turner T. Early-onset neonatal sepsis and antibiotic use in Indonesia: a descriptive, cross-sectional study. BMC Public Health 2022; 22:992. [PMID: 35581620 PMCID: PMC9112545 DOI: 10.1186/s12889-022-13343-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early diagnosis and prompt antibiotic treatment are crucial to reducing morbidity and mortality of early-onset sepsis (EOS) in neonates. However, this strategy remains challenging due to non-specific clinical findings and limited facilities. Inappropriate antibiotics use is associated with ineffective therapy and adverse outcomes. This study aims to determine the characteristics of EOS and use of antibiotics in the neonatal-intensive care units (NICUs) in Indonesia, informing efforts to drive improvements in the prevention, diagnosis, and treatment of EOS. METHODS A descriptive study was conducted based on pre-intervention data of the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Our study population consisted of neonates admitted within 72 h of life to the three participating NICUs. Neonates who presented with three or more clinical signs or laboratory results consistent with sepsis and who received antibiotics for 5 consecutive days were considered to have EOS. Culture-proven EOS was defined as positive blood or cerebrospinal fluid culture. Type and duration of antibiotics used were also documented. RESULTS Of 2,509 neonates, 242 cases were suspected of having EOS (9.6%) with culture-proven sepsis in 83 cases (5.0% of neonatal admissions in hospitals with culture facilities). The causative organisms were mostly gram-negative bacteria (85/94; 90.4%). Ampicillin / amoxicillin and amikacin were the most frequently prescribed antibiotics in hospitals with culture facilities, while a third-generation cephalosporin was mostly administered in hospital without culture facilities. The median durations of antibiotic therapy were 19 and 9 days in culture-proven and culture-negative EOS groups, respectively. CONCLUSIONS The overall incidence of EOS and culture-proven EOS was high in Indonesia, with diverse and prolonged use of antibiotics. Prospective antibiotic surveillance and stewardship interventions are required.
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Affiliation(s)
- Khansa Salsabila
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Nadira Mohammad Ali Toha
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Lily Rundjan
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Porjai Pattanittum
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen, Thailand
| | - Prapassara Sirikarn
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen, Thailand
| | - Rinawati Rohsiswatmo
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Setya Wandita
- Department of Child Health, Dr Sardjito Hospital, Yogyakarta, Indonesia
| | - Mohammad Hakimi
- Department of Obstetrics and Gynaecology, Gadjah Mada University, Yogyakarta, Indonesia
| | | | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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Ackermann K, Baker J, Festa M, McMullan B, Westbrook J, Li L. Computerized Clinical Decision Support Systems for the Early Detection of Sepsis Among Pediatric, Neonatal, and Maternal Inpatients: Scoping Review. JMIR Med Inform 2022; 10:e35061. [PMID: 35522467 PMCID: PMC9123549 DOI: 10.2196/35061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/27/2022] [Accepted: 03/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis is a severe condition associated with extensive morbidity and mortality worldwide. Pediatric, neonatal, and maternal patients represent a considerable proportion of the sepsis burden. Identifying sepsis cases as early as possible is a key pillar of sepsis management and has prompted the development of sepsis identification rules and algorithms that are embedded in computerized clinical decision support (CCDS) systems. OBJECTIVE This scoping review aimed to systematically describe studies reporting on the use and evaluation of CCDS systems for the early detection of pediatric, neonatal, and maternal inpatients at risk of sepsis. METHODS MEDLINE, Embase, CINAHL, Cochrane, Latin American and Caribbean Health Sciences Literature (LILACS), Scopus, Web of Science, OpenGrey, ClinicalTrials.gov, and ProQuest Dissertations and Theses Global (PQDT) were searched by using a search strategy that incorporated terms for sepsis, clinical decision support, and early detection. Title, abstract, and full-text screening was performed by 2 independent reviewers, who consulted a third reviewer as needed. One reviewer performed data charting with a sample of data. This was checked by a second reviewer and via discussions with the review team, as necessary. RESULTS A total of 33 studies were included in this review-13 (39%) pediatric studies, 18 (55%) neonatal studies, and 2 (6%) maternal studies. All studies were published after 2011, and 27 (82%) were published from 2017 onward. The most common outcome investigated in pediatric studies was the accuracy of sepsis identification (9/13, 69%). Pediatric CCDS systems used different combinations of 18 diverse clinical criteria to detect sepsis across the 13 identified studies. In neonatal studies, 78% (14/18) of the studies investigated the Kaiser Permanente early-onset sepsis risk calculator. All studies investigated sepsis treatment and management outcomes, with 83% (15/18) reporting on antibiotics-related outcomes. Usability and cost-related outcomes were each reported in only 2 (6%) of the 31 pediatric or neonatal studies. Both studies on maternal populations were short abstracts. CONCLUSIONS This review found limited research investigating CCDS systems to support the early detection of sepsis among pediatric, neonatal, and maternal patients, despite the high burden of sepsis in these vulnerable populations. We have highlighted the need for a consensus definition for pediatric and neonatal sepsis and the study of usability and cost-related outcomes as critical areas for future research. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/24899.
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Affiliation(s)
- Khalia Ackermann
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Jannah Baker
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Marino Festa
- Kids Critical Care Research, Department of Paediatric Intensive Care, Children's Hospital at Westmead, Sydney, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, Australia
| | - Johanna Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Ling Li
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Australia
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21
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Goel N, Cannell S, Davies G, Natti MS, Kirupaalar V, Abelian A, Saeed S, Smith R, Manikonda R, Pitchaikani PK, Davies D, Morris RM, Edwards L, Govindaraju R, Creese K, Jones J, Choudhary J, Rowley S, Sethuraman C, Muxworthy H, Curtis F, Donnelly P, Joishy M, Barnard I, Kenny C, Pal R, Jones K, Banerjee S. Implementation of an adapted Sepsis Risk Calculator algorithm to reduce antibiotic usage in the management of early onset neonatal sepsis: a multicentre initiative in Wales, UK. Arch Dis Child Fetal Neonatal Ed 2022; 107:303-310. [PMID: 34551917 DOI: 10.1136/archdischild-2020-321489] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/06/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Assess the impact of introducing a consensus guideline incorporating an adapted Sepsis Risk Calculator (SRC) algorithm, in the management of early onset neonatal sepsis (EONS), on antibiotic usage and patient safety. DESIGN Multicentre prospective study SETTING: Ten perinatal hospitals in Wales, UK. PATIENTS All live births ≥34 weeks' gestation over a 12-month period (April 2019-March 2020) compared with infants in the preceding 15-month period (January 2018-March 2019) as a baseline. METHODS The consensus guideline was introduced in clinical practice on 1 April 2019. It incorporated a modified SRC algorithm, enhanced in-hospital surveillance, ongoing quality assurance, standardised staff training and parent education. The main outcome measure was antibiotic usage/1000 live births, balancing this with analysis of harm from delayed diagnosis and treatment, disease severity and readmissions from true sepsis. Outcome measures were analysed using statistical process control charts. MAIN OUTCOME MEASURES Proportion of antibiotic use in infants ≥34 weeks' gestation. RESULTS 4304 (14.3%) of the 30 105 live-born infants received antibiotics in the baseline period compared with 1917 (7.7%) of 24 749 infants in the intervention period (45.5% mean reduction). All 19 infants with culture-positive sepsis in the postimplementation phase were identified and treated appropriately. There were no increases in sepsis-related neonatal unit admissions, disease morbidity and late readmissions. CONCLUSIONS This multicentre study provides evidence that a judicious adaptation of the SRC incorporating enhanced surveillance can be safely introduced in the National Health Service and is effective in reducing antibiotic use for EONS without increasing morbidity and mortality.
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Affiliation(s)
- Nitin Goel
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Gemma Davies
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
| | | | | | - Artur Abelian
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Shakir Saeed
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Rhian Smith
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Ravi Manikonda
- Department of Paediatrics, Nevill Hall Hospital, Abergavenny, UK
| | | | - Dawn Davies
- Department of Paediatrics, Bronglais General Hospital, Aberystwyth, Ceredigion, UK
| | - Rachel May Morris
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Lynsey Edwards
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Kate Creese
- Department of Paediatrics, Princess of Wales Hospital, Bridgend, UK
| | - Jane Jones
- Department of Paediatrics, Wrexham Maelor Hospital, Wrexham, UK
| | - Jalil Choudhary
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Sarah Rowley
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | | | - Helen Muxworthy
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | - Felicity Curtis
- Department of Women's Health, Singleton Hospital, Swansea, UK
| | | | - Manohar Joishy
- Department of Paediatrics, Ysbyty Gwynedd, Bangor, Gwynedd, UK
| | - Ian Barnard
- Department of Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Celyn Kenny
- Department of Neonatal Medicine, University Hospital of Wales, Cardiff, UK
| | - Rajarshi Pal
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Karen Jones
- Department of Paediatrics, Glangwili General Hospital, Carmarthen, Carmarthenshire, UK
| | - Sujoy Banerjee
- Department of Neonatal Medicine, Singleton Hospital, Swansea, UK
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22
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Hershkovich–Shporen C, Guri A, Gluskina T, Flidel‐Rimon O. Centers for disease control and prevention guidelines identified more neonates at risk of early-onset sepsis than the Kaiser-Permanente calculator. Acta Paediatr 2022; 111:767-771. [PMID: 34932840 DOI: 10.1111/apa.16232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 01/25/2023]
Abstract
AIM Our aim was to retrospectively compare how many cases of early-onset sepsis (EOS) would have been predicted by the the Kaiser-Permanente (KP) calculator and the United States Centers for Disease Control and Prevention (CDC) guidelines. METHODS This observational retrospective cohort study comprised 50 newborn infants with documented EOS who were born at the Kaplan Medical Centre, Israel, between 2001 and 2018. We retrospectively evaluated whether the KP calculator and the CDC recommendations would have recommended antibiotic treatment if they had been implemented within four hours of birth. RESULTS EOS was diagnosed in 50 of the 109 877 infants born from 34 weeks of gestation. By four hours of birth, 18 were symptomatic, five had an equivocal clinical status, and 27 were asymptomatic. The KP calculator would have recommended antibiotic treatment for 19 (38%) neonates: 18 who were symptomatic and one who was initially asymptomatic. The CDC guidelines would have recommended antibiotic treatment for 27 (54%) nenonates: those 19 plus all 5 with equivocal status and other 3 who were asymptomatic. CONCLUSION Using the CDC guidelines would have identified more equivocal and asymptomatic EOS cases within four hours of birth than the KP calculator. Enhanced observation is recommended when using the KP calculator.
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Affiliation(s)
- Calanit Hershkovich–Shporen
- Department of Neonatology Kaplan Medical Centre Rehovot Israel
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
| | - Alex Guri
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
- Department of Paediatrics Kaplan Medical Centre Rehovot Israel
- Infectious Diseases Unit Kaplan Medical Centre Rehovot Israel
| | - Tatiana Gluskina
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
- Department of Paediatrics Kaplan Medical Centre Rehovot Israel
| | - Orna Flidel‐Rimon
- Department of Neonatology Kaplan Medical Centre Rehovot Israel
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
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23
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Kopsidas I, Molocha NM, Kourkouni E, Coffin S, Gkentzi D, Chorianopoulou E, Dimitriou G, Kapetanaki A, Karavana G, Lithoxopoulou M, Polychronaki M, Roilides E, Triantafyllidou P, Triantafyllou C, Tsopela GC, Tsouvala E, Tsolia MN, Zaoutis T, Spyridis N. Potential benefit from the implementation of the Kaiser Permanente neonatal early-onset sepsis calculator on clinical management of neonates with presumed sepsis. Eur J Pediatr 2022; 181:1001-1008. [PMID: 34664107 DOI: 10.1007/s00431-021-04282-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
To assess the potential benefit from the implementation of the Kaiser Permanente early-onset sepsis calculator (EOS-C), in terms of antibiotic use and requested laboratory tests, in a network of neonatal intensive care units (NICUs) in Greece, and to determine the incidence of early-onset sepsis (EOS) in Greek NICUs, a prospective surveillance study was conducted in 7 NICUs between April 2018 and June 2019. Data were collected for all newborns ≥ 34 weeks' gestation receiving empiric antibiotic therapy within the first 3 days of life. The number of live births and positive blood or cerebrospinal fluid cultures within the first 3 days of life were used for calculation of EOS incidence. Evaluation of possible impact of implementing the calculator was done by comparing the clinicians' recorded management to the calculator's suggested course of action. The unit-specific incidence of culture-proven EOS ranged between 0 and 2.99/1000 live births. The weighted incidence rate for all 7 units was 1.8/1000 live births. Management of EOS guided by the calculator could lead to a reduction of empiric antibiotic initiation up to 100% for the group of "well-appearing" neonates and 86% for "equivocal," lowering exposure to antibiotics by 4.2 and 3.8 days per neonate, respectively. Laboratory tests for blood cultures drawn could be reduced by up to 100% and 68%, respectively. Sensitivity of the EOS-C in identifying neonates with positive blood cultures was high.Conclusion: Management strategies based on the Kaiser Permanente neonatal sepsis calculator may significantly reduce antibiotic exposure, invasive diagnostic procedures, and hospitalizations in late preterm and term neonates. What is Known: • Neonates are frequently exposed to antibiotics for presumed EOS. • The Kaiser Permanente sepsis calculator can reduce antibiotic exposure in neonates.. What is New: • EOS calculator can be an effective antibiotic stewardship tool in a high prescribing country and can reduce invasive diagnostic procedures and mother-baby separation. • Incidence of EOS in Greece is higher compared to other European countries.
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Affiliation(s)
- Ioannis Kopsidas
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece.,Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece
| | | | - Eleni Kourkouni
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Susan Coffin
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Despoina Gkentzi
- Department of Pediatrics, University General Hospital of Patras, Patras Medical School, Patras, Greece
| | | | - Gabriel Dimitriou
- Department of Pediatrics, University General Hospital of Patras, Patras Medical School, Patras, Greece
| | - Anastasia Kapetanaki
- Neonatal Intensive Care Unit, Elenas Venizelou Maternity Hospital, Athens, Greece
| | - Georgia Karavana
- Neonatal Intensive Care Unit, General Hospital of Nikaia and Piraeus "Aghios Panteleimon", Athens, Greece
| | - Maria Lithoxopoulou
- Second Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Emmanuel Roilides
- Third Department of Pediatrics, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | - Emmanouela Tsouvala
- Neonatal Intensive Care Unit, General University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Maria N Tsolia
- Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece
| | - Theoklis Zaoutis
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece.,Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Nikos Spyridis
- Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece.
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24
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Abstract
Chorioamnionitis or intrauterine inflammation is a frequent cause of preterm birth. Chorioamnionitis can affect almost every organ of the developing fetus. Multiple microbes have been implicated to cause chorioamnionitis, but "sterile" inflammation appears to be more common. Eradication of microorganisms has not been shown to prevent the morbidity and mortality associated with chorioamnionitis as inflammatory mediators account for continued fetal and maternal injury. Mounting evidence now supports the concept that the ensuing neonatal immune dysfunction reflects the effects of inflammation on immune programming during critical developmental windows, leading to chronic inflammatory disorders as well as vulnerability to infection after birth. A better understanding of microbiome alterations and inflammatory dysregulation may help develop better treatment strategies for infants born to mothers with chorioamnionitis.
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25
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Mundal HS, Rønnestad A, Klingenberg C, Stensvold HJ, Størdal K. Antibiotic Use in Term and Near-Term Newborns. Pediatrics 2021; 148:183440. [PMID: 34814187 DOI: 10.1542/peds.2021-051339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We aimed to study whether national and local antibiotic stewardship projects have reduced the antibiotic use in newborns and to monitor potential changes in adverse outcomes. METHODS In a nationwide, population-based study from Norway, we included all hospital live births from 34 weeks' gestation (n = 282 046) during 2015 to 2019. The primary outcome was the proportion of newborns treated with antibiotics from 0 to 28 days after birth. The secondary outcomes were the overall duration of antibiotic treatment and by categories: culture-positive sepsis, clinical sepsis, and no sepsis. RESULTS A total of 7365 (2.6%) newborns received intravenous antibiotics during the period, with a reduction from 3.1% in 2015 to 2.2% in 2019 (30% decrease; P < .001). Hospitals with antibiotic stewardship projects experienced the largest reduction (48% vs 23%; P < .001). We found a small decrease in the median duration of antibiotic treatment in newborns without sepsis from 2.93 to 2.66 days (P = .011), and geographical variation was reduced during the study period. The overall number of days with antibiotic treatments was reduced by 37% from 2015 to 2019 (119.1 of 1000 vs 75.6 of 1000; P < .001). Sepsis was confirmed by blood culture in 206 newborns (incidence rate: 0.73 cases per 1000 live births). We found no increase in sepsis with treatment onset >72 hours of life, and sepsis-attributable deaths remained at a low level. CONCLUSIONS During the study period, a substantial decrease in the proportion of newborns treated with antibiotics was observed together with a decline in treatment duration for newborns without culture-positive sepsis.
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Affiliation(s)
| | - Arild Rønnestad
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø-The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Hans Jørgen Stensvold
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway
| | - Ketil Størdal
- NICU, Clinic of Pediatric and Adolescent Medicine.,Pediatric Research Institute, Faculty of Medicine, University of Oslo, Oslo, Norway
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26
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Kothari N, Dsouza V, Mishra U, Maheshwari R, Shah D, D’Cruz D, Baird J, Luig M, Jani P. Asymptomatic full-term infants born to women with chorioamnionitis may not need routine antibiotics. Acta Paediatr 2021; 110:3000-3005. [PMID: 34358357 DOI: 10.1111/apa.16059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 11/28/2022]
Abstract
AIM While infants with early-onset sepsis require antibiotics, there is little evidence to support their routine use in asymptomatic infants exposed to maternal chorioamnionitis. We aimed to ascertain the incidence of culture-proven sepsis in full-term infants exposed to chorioamnionitis and to determine whether asymptomatic infants need routine antibiotic treatment. METHODS This study was retrospective. Included were all full-term infants admitted to our neonatal intensive care unit between 1 January 2017 and 31 May 2018 who were given intravenous antibiotics for maternal chorioamnionitis. After identifying eligible infants, relevant maternal and infant data were collected from our medical records and the Neonatal Intensive Care Units Database. RESULTS We selected 167 term infants from 7736 deliveries. The incidence of chorioamnionitis was 21 per 1000 deliveries. The mean gestational age was 39 weeks (range 37-41), and 57% infants were male. Asymptomatic infants (76%) received intravenous antibiotics for an average of 2 days compared to 4 days in the symptomatic group (24%), p < 0.001. No infant died or developed culture-positive sepsis. CONCLUSION The risk of early-onset sepsis in well-appearing term infants of mothers with chorioamnionitis is low. Further studies are mandatory to determine whether asymptomatic infants of mothers with clinical chorioamnionitis need antibiotic treatment.
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Affiliation(s)
- Nakul Kothari
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Vanessa Dsouza
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Umesh Mishra
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Rajesh Maheshwari
- Department of Neonatology Westmead Hospital Westmead NSW Australia
- The University of Sydney Sydney NSW Australia
| | - Dharmesh Shah
- Department of Neonatology Westmead Hospital Westmead NSW Australia
- The University of Sydney Sydney NSW Australia
| | - Daphne D’Cruz
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Jane Baird
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Melissa Luig
- Department of Neonatology Westmead Hospital Westmead NSW Australia
| | - Pranav Jani
- Department of Neonatology Westmead Hospital Westmead NSW Australia
- The University of Sydney Sydney NSW Australia
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27
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Reducing Blood Culture and Antibiotic Usage in Neonates. Adv Neonatal Care 2021; 22:309-316. [DOI: 10.1097/anc.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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van Hasselt TJ, McDermott H, Surana P, Eltahir R, Macaskill L, Jain R, McMullan N, Slee S, Jagga M, Naseem M, Alake O, Cherry C, Miguras B, Ewer AK. Impact of neonatal sepsis calculator in West Midlands (UK). Arch Dis Child Fetal Neonatal Ed 2021; 106:568-569. [PMID: 33293276 DOI: 10.1136/archdischild-2020-320862] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Tim J van Hasselt
- Neonatal Intensive Care Unit, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Helen McDermott
- Neonatal Intensive Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pinki Surana
- Neonatal Intensive Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rawia Eltahir
- Neonatal Unit, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, Shropshire, UK
| | - Laura Macaskill
- Neonatal Unit, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Nicola McMullan
- Neonatal Unit, Dudley Group of Hospitals NHS Trust, Dudley, West Midlands, UK
| | - Samantha Slee
- Neonatal Intensive Care Unit, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Megha Jagga
- Neonatal Intensive Care Unit, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Muhammed Naseem
- Neonatal Intensive Care Unit, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Oluwaseyi Alake
- Neonatal Intensive Care Unit, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Canada Cherry
- Neonatal Unit, Good Hope Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Benjamin Miguras
- Neonatal Intensive Care Unit, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Andrew K Ewer
- Neonatal Intensive Care Unit, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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29
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Retrospective cohort study of neonatal early onset of sepsis and the role of the EOS calculator in a level II nursery. Pediatr Neonatol 2021; 62:512-521. [PMID: 34092529 DOI: 10.1016/j.pedneo.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/31/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis is a major cause of mortality and morbidity in neonates. With the improvement in health care standards, the incidence of neonatal Early Onset Sepsis (EOS) has reduced significantly. A recent Web-based EOS-calculator has been introduced with the aim to reduce the use of IV antibiotics in neonates. The role of the EOS-calculator has yet to be ascertained in this regional Special Care Nursery (SCN) in Western Australia. This study aims at examining the local incidence of culture proven EOS and the role of the EOS calculator. METHOD It is a retrospective study examining all newborns ≥35 weeks gestation throughout 2019 (Jan-Dec 2019) who received IV-antibiotics. The local incidence of culture-proven EOS was established and applied onto the EOS calculator. The recommended management by the EOS-calculator was cross-examined with the local EOS guideline. Overall proportion of reduction in IV antibiotics use was formulated. Other relevant laboratory data extracted was analysed with Pearson's correlation test with the EOS scores. RESULTS Total included sample was n = 252 with an annual birth of 1880s indicating 13.4% of all neonates born throughout year 2019 was treated with IV antibiotics. The local incidence of culture-proven EOS was 0.5/1000. By applying the EOS-calculator, a significant reduction of IV antibiotics usage from 13.4% to 3.9% (z value 10.4, p < 0.0001) could be achieved in this cohort. Sixty three percent of neonates who received IV antibiotics in this cohort were classified as 'clinically well' based on the EOS-calculator. CONCLUSION The EOS-calculator could reduce the use of IV antibiotics in the neonatal population significantly in this regional SCN (from 13.4% to 3.9%). Judicial use of IV antibiotics is imperative as part of the holistic care for the neonates. Implementation of the EOS-calculator must be done strategically considering the local incidence of EOS and other health care policies.
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30
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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; 10:1046. [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] [Grants] [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.)
| | - 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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[Sepsis risk calculator-guided antibiotic management in neonates with suspected early-onset sepsis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021. [PMID: 34130779 PMCID: PMC8213997 DOI: 10.7499/j.issn.1008-8830.2101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the efficacy of sepsis risk calculator (SRC) in guiding antibiotic use in neonates with suspected early-onset sepsis (EOS). METHODS A total of 284 neonates with a gestational age of ≥ 35 weeks were enrolled as the control group, who were hospitalized in the Children's Hospital of Chongqing Medical University from March to July, 2019 and were suspected of EOS. Their clinical data were retrospectively collected and the use of antibiotics was analyzed based on SRC. A total of 170 neonates with a gestational age of ≥ 35 weeks were enrolled as the study group, who were admitted to the hospital from July to November, 2020 and were suspected of EOS. SRC was used prospectively for risk scoring to assist the decision making of clinical antibiotic management. The two groups were compared in terms of the rate of use of antibiotics, blood culture test rate, clinical outcome, and adherence to the use of SRC. RESULTS Compared with the control group, the study group had a significantly higher SRC score at birth and on admission (P < 0.05). The rate of use of antibiotics in the study group was significantly lower than that in the control group[84.7% (144/170) vs 91.5% (260/284), 6.8% decrease; P < 0.05]. The blood culture test rate in the study group was also significantly lower than that in the control group (85.3% vs 91.9%, P < 0.05). There was no significant difference between the two groups in the incidence rate of adverse outcomes and the final diagnosis of EOS (P > 0.05). CONCLUSIONS The use of SRC reduces the rate of empirical use of antibiotics in neonates with suspected EOS and does not increase the risk of adverse outcomes, and therefore, it holds promise for clinical application.
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Huseynova R, Bin Mahmoud L, Hamad Aljobair F, Huseynov O, Career H, Jaganathan PP, Abdelrahim A, Abduljabar Alaklobi FA. Use of Early-Onset Sepsis Risk Calculator for Neonates ≥ 34 Weeks in a Large Tertiary Neonatal Centre, Saudi Arabia. Cureus 2021; 13:e14620. [PMID: 34040919 PMCID: PMC8140202 DOI: 10.7759/cureus.14620] [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] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Early-onset sepsis (EOS) refers to sepsis with onset before 72 hours of life. Kaiser Permanente Calculator (KPC) or EOS risk calculator is an advanced multivariate risk model for predicting EOS in infants. Objective To examine the EOS risk calculator effect for predicting neonatal EOS, the necessity for laboratory tests, antibiotic usage, and length of hospital stay among the term and late-preterm newborns. Method In this cross-sectional study, we evaluated 44 cases of neonates ≥34 weeks of gestation started on empiric antibiotics within 72 hours after birth due to suspected EOS at the neonatal intensive care unit (NICU). The study site is a 1,500-bed teaching hospital, with around 4,500 annual deliveries, 70 beds in the level II and level III tertiary care NICU. We calculated the risk of the incidence of EOS as one per 1000 live births. Then we retrospectively calculated the probability of neonatal early-onset infection at birth based on the EOS risk calculator and assigned each neonate to one of the recommended categories of the calculator. The primary outcome was to evaluate the infection risk calculator's effect for predicting neonatal EOS and antibiotic usage among the term and late-preterm newborns ≥34 weeks of gestation. Results In our data, EOS calculator showed unnecessary antibiotic usage for 12 (27.3%) neonates [relative risk reduction (RRR) 27.2%; 95% confidence interval (CI) 20.3% - 35.7%)]. EOS risk calculator implementation may decrease in the number of NICU admission (RRR 20.4%; 95% CI 14.3% - 28%), laboratory tests (RRR 20.4%; 95% CI 14.3% - 28%), and length of stay (RRR 25%; 95% CI 38% - 95%). Conclusion EOS calculator could be considered a strategic and objective implementation for managing EOS that can limit unnecessary laboratory tests, reduce antibiotic usage, and length of stay related to EOS. Our findings ensure a multicenter, randomized study evaluating the safety and general use of the calculator for EOS sepsis in Saudi Arabia's clinical practice.
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Affiliation(s)
- Roya Huseynova
- Neonatal Intensive Care Unit, King Saud Medical City, Riyadh, Riyadh, SAU
| | - Latifa Bin Mahmoud
- Neonatal Intensive Care Unit, King Saud Medical City, Riyadh, Riyadh, SAU
| | | | - Ogtay Huseynov
- Neurosurgery Resident, Azerbaijan Medical University, Baku, AZE
| | - Halima Career
- Obstetrics and Gynecology, King Saud Medical City, Riyadh, Riyadh, SAU
| | | | - Adli Abdelrahim
- Neonatal Intensive Care Unit, King Saud Medical City, Riyadh, Riyadh, SAU
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A comparison between risk-factor guidance for neonatal early-onset sepsis and Kaiser Permanente sepsis risk calculator in a Greek cohort. Early Hum Dev 2021; 155:105331. [PMID: 33607601 DOI: 10.1016/j.earlhumdev.2021.105331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of neonates with early-onset sepsis (EOS) is based on maternal risk factors and infant clinical indications. An online sepsis risk calculator (SRC) has been established taking into consideration how clinical appearance modifies the initial risk for EOS. AIMS To compare our clinical practice based on risk-factor guidance with that projected through the application of the SRC. STUDY DESIGN Retrospective cohort study. METHODS All neonates ≥34 weeks' gestation, during 01/2019-8/2020. The SRC was applied retrospectively to determine the recommendation. EOS was defined based on a positive blood or cerebrospinal fluid culture-proven infection within 72 h of age. Clinical sepsis was defined according to the European Medicine Agency criteria. OUTCOME MEASURES Differences on antibiotic administration and management. RESULTS Overall, 2084 infants were identified, of whom 150 (7%) received antibiotics. Of them, 34 infants were diagnosed with clinical sepsis, while one was diagnosed with culture positive-proven EOS. Applying SRC, 87 (4%) infants would have received antibiotics. Clinical sepsis was diagnosed in 29 infants, while one infant had culture positive-proven EOS. Sixty-seven of 150 (45%) infants that received antibiotics would not have been treated based on SRC; five infants that developed clinical sepsis would have been missed with SRC. A 99.7% agreement between both guidance was found regarding infants not indicated for antibiotics. SRC application led to an absolute reduction of antibiotic administration by 2.93% (95% CI 2.19-3.75), p < 0.0001. CONCLUSIONS The adoption of SRC would have significantly reduced antibiotic usage; however, a significant portion of cases with clinical EOS would have been missed.
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Kimpton JA, Verma A, Thakkar D, Teoh S, Verma A, Piyasena C, Battersby C. Comparison of NICE Guideline CG149 and the Sepsis Risk Calculator for the Management of Early-Onset Sepsis on the Postnatal Ward. Neonatology 2021; 118:562-568. [PMID: 34518475 DOI: 10.1159/000518059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The NICE guideline CG149 has increased the number of well infants receiving antibiotics for suspected early-onset sepsis (EOS). The Kaiser Permanente sepsis risk calculator (SRC) has safely and dramatically reduced investigations and antibiotics for suspected EOS in the USA. This study evaluates the current management of suspected EOS against the NICE guideline CG149 and the SRC. METHODS This study is a prospective, multicentre, observational study across 13 neonatal units in London. Infants were born between June and August 2019 at ≥34 weeks gestation and commenced on antibiotics for suspected EOS and cared for on postnatal/transitional care wards. Data were prospectively recorded: risk factors, clinical indicators, investigations, and results. Outcome measures included the following: (1) incidence of EOS and (2) proportion of infants recommended for antibiotics by NICE versus theoretical application of SRC. RESULTS 1,066/8,856 (12%) infants on postnatal/transitional care wards received antibiotics, 7 of whom had a positive blood culture (group B Streptococcus = 6 and Escherichia coli = 1), making the EOS incidence 0.8/1,000 infants. Six hundred one infants had data for SRC analysis, which recommended "antibiotics" or "blood culture" for 130/601 (21.6%) infants using an EOS incidence of 0.5/1,000 versus 527/601 (87.7%) if NICE was applied. CONCLUSIONS Currently, 12.0% of infants on postnatal/transitional care wards receive antibiotics for suspected EOS. The SRC could dramatically reduce antibiotic use, but further prospective studies are required to evaluate safety of SRC implementation.
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Affiliation(s)
| | - Amit Verma
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Sophia Teoh
- Croydon University Hospital, Croydon, United Kingdom
| | - Aarti Verma
- Southend University Hospital NHS Foundation Trust, London, United Kingdom
| | - Chinthika Piyasena
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Cheryl Battersby
- Imperial College London, London, United Kingdom.,Chelsea and Westminster Hospital, London, United Kingdom
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Morris R, Jones S, Banerjee S, Collinson A, Hagan H, Walsh H, Thornton G, Barnard I, Warren C, Reid J, Busfield A, Matthes J. Comparison of the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with NICE guideline CG149 in infants ≥34 weeks' gestation who developed early-onset sepsis. Arch Dis Child Fetal Neonatal Ed 2020; 105:581-586. [PMID: 32170032 DOI: 10.1136/archdischild-2019-317165] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 01/17/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with National Institute for Health and Care Excellence (NICE) guideline CG149 in infants ≥34 weeks' gestation who developed early-onset sepsis (EOS). DESIGN Retrospective multicentre study. SETTING Five maternity services in South West of England and Wales. PATIENTS 70 infants with EOS (<72 hours) confirmed on blood or cerebrospinal fluid culture. METHODS Retrospective virtual application of NICE and SRC through review of maternal and neonatal notes. MAIN OUTCOME MEASURE The number of infants recommended antibiotics by 4 hours of birth. RESULTS The incidence of EOS ≥34 weeks was 0.5/1000 live births. Within 4 hours of birth, antibiotics were recommended for 39 infants (55.7%) with NICE, compared with 27 (38.6%) with SRC. The 12 infants advised early treatment by NICE but not SRC remained well, only one showing transient mild symptoms after 4 hours. Another four babies received antibiotics by 4 hours outside NICE and SRC guidance. The remaining 27 infants (38.6%) received antibiotics when symptomatic after 4 hours. Only one infant who was unwell from birth, died. Eighty-one per cent of all EOS infants were treated for clinical reasons rather than for risk factors alone. CONCLUSION While both tools were poor in identifying EOS within 4 hours, NICE was superior to SRC in identifying asymptomatic cases. Currently, four out of five EOS have symptoms at first identification, the majority of whom present within 24 hours of birth. Antibiotic stewardship programmes using SRC should include enhanced observation for infants currently treated within NICE guidance.
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Affiliation(s)
- Rachel Morris
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
| | - Steve Jones
- Paediatrics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sujoy Banerjee
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
| | | | - Hannah Hagan
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Hannah Walsh
- Paediatrics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Graham Thornton
- Paediatrics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Ian Barnard
- Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Wales, UK
| | - Chris Warren
- Paediatrics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Jennifer Reid
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Alison Busfield
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Jean Matthes
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
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