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Kontou A, Agakidou E, Chatziioannidis I, Chotas W, Thomaidou E, Sarafidis K. Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:871. [PMID: 39062320 PMCID: PMC11275925 DOI: 10.3390/children11070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.
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Affiliation(s)
- Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Ilias Chatziioannidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Evanthia Thomaidou
- Department of Anesthesia and Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, AHEPA University General Hospital of Thessaloniki, 54621 Thessaloniki, Greece;
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
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Menegolla MP, Silveira RC, Görgen ARH, Gandolfi FE, Procianoy RS. Antibiotics and beyond: Unraveling the dynamics of bronchopulmonary dysplasia in very preterm infants. Pediatr Pulmonol 2024. [PMID: 39023342 DOI: 10.1002/ppul.27182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 06/14/2024] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) remains a significant challenge in neonatal care. Prenatal inflammation and neonatal sepsis contribute to the multifactorial nature of BPD. A potential association between empirical antibiotic therapy and BPD risk has been proposed due to microbiota dysbiosis in very low birth weight premature infants. METHODS A single centered retrospective cohort study of preterm infants (24-32 weeks gestation) from 2014 to 2021. The study compared groups that received empirical antibiotics in the first days of life and those that did not receive any antibiotic in the first days of life. The primary outcomes studied were BPD, death, and the combined outcome of BPD/death. Statistical analysis employed t-tests, Mann-Whitney U, Chi-square, and logistic regression. RESULTS Of 454 preterm infants, 61.5% received antibiotics. This group had lower gestational age, birth weight, and Apgar scores. Antibiotic use was associated with higher incidence of BPD (35.5% vs. 10.3%), death (21.5% vs. 8.6%), and combined outcomes (54.5% vs. 18.3%). In multivariate analysis, antibiotic use independently associated with BPD (OR 2.58, p < 0.001) and combined outcome BPD/death (OR 2.06, p < 0.02). Antenatal corticosteroids provided protection against BPD, but not mortality. CONCLUSION This study suggests an association between early empirical antibiotic use and BPD in preterm infants, emphasizing the need for judicious antibiotic practices in neonatal care.
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Affiliation(s)
- Marina P Menegolla
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Rita C Silveira
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Antônio R H Görgen
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Fernanda E Gandolfi
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Renato S Procianoy
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Newborn Section, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Payton KSE, Bennett MV, Schulman J, Benitz WE, Stellwagen L, Darmstadt GL, Quinn J, Kristensen-Cabrera AI, Breault CC, Bolaris M, Lefrak L, Merrill J, Sharek PJ. 28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use. J Perinatol 2024; 44:1061-1068. [PMID: 38378826 PMCID: PMC11226396 DOI: 10.1038/s41372-024-01885-8] [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: 06/08/2023] [Revised: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention. CONCLUSION Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.
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Affiliation(s)
- Kurlen S E Payton
- Department of Pediatrics, Division of Neonatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA.
| | - Mihoko V Bennett
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph Schulman
- CA Department of Health Care Services, California Children's Services, Sacramento, CA, USA
| | - William E Benitz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lisa Stellwagen
- Department of Pediatrics, Division of Academic General Pediatrics, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jenny Quinn
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | | | - Courtney C Breault
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
| | - Michael Bolaris
- Department of Pediatrics, Division of Infectious Disease, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Linda Lefrak
- California Department of Public Health, Center for Health Care Quality, Health Care Associated Infections Program, Richmond, CA, USA
| | - Jeff Merrill
- Sutter Health Summit Medical Center, Oakland, CA, USA
| | - Paul J Sharek
- California Perinatal Quality Care Collaborative (CPQCC), Stanford, CA, USA
- Department of Pediatrics, Division of Hospitalist Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Department of Pediatrics, Division of Hospitalist Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Center for Quality and Patient Safety, Seattle Children's Hospital, Seattle, WA, USA
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4
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Ye F, Cai S, Cao B, Cheng L, Fan H, Huang Y, Jiang S, Lai G, Li Y, Shi Y, She D, Su X, Tang K, Wang H, Wang L, Xu B, Xu J, Zhang J, Zhang J, Zhang T, Zhang W, Zhang Y, Zhou H, Hu J, Huang X, Jiang E, Liu Q, Wang J, Wu D, Zhang X, Kang Y, Qiu H, Gu B, Sun B, Xu Y, Cao C, Li R, Pan W, Zhuo C, Zhu L, Huang H, Tong R, Zhang J, Jiang M, Qu J. Consensus for antifungal stewardship in China (2024 edition). J Thorac Dis 2024; 16:4016-4029. [PMID: 38983176 PMCID: PMC11228704 DOI: 10.21037/jtd-24-13] [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: 01/03/2024] [Accepted: 05/17/2024] [Indexed: 07/11/2024]
Abstract
Background Invasive fungal disease (IFD) has become a serious threat to human health in China and around the world, with high mortality and morbidity. Currently, the misdiagnosis rate of IFD is extremely high, compounded with the low quality of prescription antifungals and the high incidence of adverse events associated with IFD treatment, resulting in lengthy hospitalization, low clinical response, and high disease burden, which have become serious challenges in clinical practice. Antifungal stewardship (AFS) can not only significantly increase the early diagnosis rate of IFD, reduce inappropriate utilization of antifungal drugs, improve patient prognosis, but can also improve therapeutic safety and reduce healthcare expenses. Thus, it is urgent to identify key AFS metrics suitable for China's current situation. Methods Based on metrics recommended by international AFS consensuses, combined with the current situation of China and the clinical experience of authoritative experts in various fields, several metrics were selected, and experts in the fields of respiratory diseases, hematology, intensive care units (ICUs), dermatology, infectious diseases, microbiology laboratory and pharmacy were invited to assess AFS metrics by the Delphi method. Consensus was considered to be reached with an agreement level of ≥80% for the metric. Results Consensus was reached for 24 metrics, including right patient metrics (n=4), right time metrics (n=3), and right use metrics (n=17). Right use metrics were further subdivided into drug choice (n=8), drug dosage (n=4), drug de-escalation (n=1), drug duration (n=2), and drug consumption (n=2) metrics. Forty-six authoritative experts assessed and reviewed the above metrics, and a consensus was reached with a final agreement level of ≥80% for 22 metrics. Conclusions This consensus is the first to propose a set of AFS metrics suitable for China, which helps to establish AFS standards in China and is also the first AFS consensus in Asia, and may improve the standard of clinical diagnosis and treatment of IFD, and guide hospitals to implement AFS, ultimately promoting the rational use of antifungal drugs and improving patient prognosis.
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Affiliation(s)
- Feng Ye
- The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, Guangzhou National Laboratory, Guangzhou Medical University, Guangzhou, China
| | - Shaoxi Cai
- Department of Pulmonary Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Linling Cheng
- The First Affiliated Hospital of Guangzhou Medical University, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Department of Pulmonary and Critical Care Medicine, Guangzhou Institute of Respiratory Health, Guangzhou National Laboratory, Guangzhou Medical University, Guangzhou, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai Hospital, Navy Medical University, Shanghai, China
| | - Shanping Jiang
- Department of Pulmonary and Critical Care Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guoxiang Lai
- Department of Pulmonary and Critical Care Medicine, The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Yuping Li
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi Shi
- Department of Pulmonary and Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Danyang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Kejing Tang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hongmin Wang
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lingwei Wang
- Department of Pulmonary and Critical Care Medicine, Shenzhen People’s Hospital, Shenzhen, China
| | - Bin Xu
- Jiangxi Health Committee Key (JHCK) Laboratory of Tumor Metastasis, Jiangxi Cancer Hospital, Nanchang, China
| | - Jinfu Xu
- Department of Pulmonary and Critical Care Medicine, Tongji University Affiliated Shanghai Pulmonary Hospital, Shanghai, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianquan Zhang
- Department of Pulmonary and Critical Care Medicine, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Tiantuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Zhang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yunhui Zhang
- Department of Pulmonary and Critical Care Medicine, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Hua Zhou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianda Hu
- Department of Hematology, The Second Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People’s Hospital, Beijing, China
| | - Erlie Jiang
- Department of Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jingbo Wang
- Department of Hematology, Aerospace Center Hospital, Beijing, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xi Zhang
- Department of Hematology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, West China Tianfu Hospital, Chengdu, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital Southeast University, Nanjing, China
| | - Bing Gu
- Department of Laboratory Medicine, Guangdong Provincial People’s Hospital, Guangzhou, China
| | - Baoqing Sun
- Department of Clinical Laboratory, National Center for Respiratory Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yingchun Xu
- Department of Laboratory Medicine, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Cunwei Cao
- Department of Dermatology and Venerology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruoyu Li
- Department of Dermatology and Venereology, Peking University First Hospital, National Clinical Research Centre for Skin and Immune Diseases, Beijing, China
| | - Weihua Pan
- Department of Dermatology, Shanghai Changzheng Hospital, Shanghai, China
| | - Chao Zhuo
- Department of Infectious Disease, State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liping Zhu
- Department of Infectious Disease, Huashan Hospital, Fudan University, Shanghai, China
| | - Haihui Huang
- Department of Infectious Disease, Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Rongsheng Tong
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
| | - Jing Zhang
- Department of Pharmacy, Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Mei Jiang
- Department of Biostatistics, National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Dramowski A, Prusakov P, Goff DA, Brink A, Govender NP, Annor AS, Balfour L, Bekker A, Cassim A, Gijzelaar M, Holgate SL, Kolman S, Messina A, Tootla H, Schellack N, van Jaarsveld A, Reddy K, Pillay S, Conradie L, van Niekerk AM, Bester T, Alexander P, Andrews A, Dippenaar M, Bamford C, Brits S, Chirwa P, Erasmus H, Ekermans P, Gounden P, Kriel T, Mawela D, Moncho M, Mphuthi T, Nhari R, Charani E, Sánchez PJ, Bergh DVD. Prospective antimicrobial stewardship interventions by multidisciplinary teams to reduce neonatal antibiotic use in South Africa: The Neonatal Antimicrobial Stewardship (NeoAMS) study. Int J Infect Dis 2024; 146:107158. [PMID: 38945432 DOI: 10.1016/j.ijid.2024.107158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/07/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Hospitalized neonates are vulnerable to infection and have high rates of antibiotic utilization. METHODS Fourteen South African neonatal units (seven public, seven private sector) assembled multidisciplinary teams involving neonatologists, microbiologists, pharmacists, and nurses to implement prospective audit and feedback neonatal antimicrobial stewardship (NeoAMS) interventions. The teams attended seven online training sessions. Pharmacists conducted weekday antibiotic prescription reviews in the neonatal intensive care unit and/or neonatal wards providing feedback to the clinical teams. Anonymized demographic and NeoAMS interventions data were aggregated for descriptive purposes and statistical analysis. FINDINGS During the 20-week NeoAMS intervention in 2022, 565 neonates were enrolled. Pharmacists evaluated seven hundred antibiotic prescription episodes; rule-out sepsis (180; 26%) and culture-negative sepsis (138; 20%) were the most frequent indications for antibiotic prescription. For infection episodes with an identified pathogen, only 51% (116/229) of empiric treatments provided adequate antimicrobial coverage. Pharmacists recommended 437 NeoAMS interventions (0·6 per antibiotic prescription episode), with antibiotic discontinuation (42%), therapeutic drug monitoring (17%), and dosing (15%) recommendations most frequent. Neonatal clinicians' acceptance rates for AMS recommendations were high (338; 77%). Mean antibiotic length of therapy decreased by 24% from 9·1 to 6·9 days (0·1 day decrease per intervention week; P = 0·001), with the greatest decline in length of therapy for culture-negative sepsis (8·2 days (95% CI 5·7-11·7) to 5·9 days (95% CI 4·6-7·5); P = 0·032). INTERPRETATION This neonatal AMS programme was successfully implemented in heterogenous and resource-limited settings. Pharmacist-recommended AMS interventions had high rates of clinician acceptance. The NeoAMS intervention significantly reduced neonatal antibiotic use, particularly for culture-negative sepsis. FUNDING A grant from Merck provided partial support.
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Affiliation(s)
- Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | | | - Debra A Goff
- The Ohio State University College of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Adrian Brink
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa; Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nelesh P Govender
- Division of the National Health Laboratory Service, National Institute for Communicable Diseases Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ama Sakoa Annor
- Department of Pharmacy, Dr George Mukhari Academic Hospital, Pretoria, South Africa; Department of Clinical pharmacy, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Liezl Balfour
- Department of Nursing, Lenmed Group, Johannesburg, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Azraa Cassim
- Department of Pharmacy, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | | | - Sandi L Holgate
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sonya Kolman
- Department of Pharmacy, Nelson Mandela Children's Hospital, Johannesburg, South Africa
| | - Angeliki Messina
- Antimicrobial Stewardship Unit, Netcare Hospitals Ltd, Johannesburg, South Africa
| | - Hafsah Tootla
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa; National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Kessendri Reddy
- Division of Medical Microbiology and Immunology, Department of Pathology, Faculty of Medicine and Health Sciences, National Health Laboratory Service Tygerberg and Stellenbosch University, Cape Town, South Africa
| | - Shakti Pillay
- Division of Neonatology, Department of Paediatrics and Child Health, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Lucinda Conradie
- Pharmacy Department, Mowbray Maternity Hospital, Cape Town, South Africa
| | - Anika M van Niekerk
- Division of Neonatology, Department of Paediatrics and Child Health, Mowbray Maternity Hospital, University of Cape Town, Cape Town, South Africa
| | - Tarina Bester
- Netcare GNE Regional Clinical Pharmacy, Pretoria, South Africa
| | - Pearl Alexander
- Department of Nursing, Lenmed Royal Hospital & Heart Centre, Kimberley, South Africa
| | - Antoinette Andrews
- Department of Nursing, Lenmed Ethekwini Hospital and Heart Centre, Durban, South Africa
| | - Magdel Dippenaar
- Pharmacy Department, Mediclinic Welkom, Welkom, Free State, South Africa
| | - Colleen Bamford
- Pathcare, East London, South Africa; Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sharnel Brits
- Pharmacy Department, George Provincial Hospital, George, South Africa
| | - Pinky Chirwa
- Neonatal Unit, Nelson Mandela Childrens Hospital, Johannesburg, South Africa
| | - Hannelie Erasmus
- Pharmacy Department, Mediclinic Welkom, Welkom, Free State, South Africa
| | - Pieter Ekermans
- Ampath Laboratory, National Reference Laboratory, Department of Medical Microbiology, Pretoria, South Africa
| | - Pebenita Gounden
- Department of Pharmacy, Lenmed Ethekwini Hospital and Heart Centre, Durban, South Africa
| | - Teresa Kriel
- Pharmacy Department, Life Beacon Bay, East London, South Africa
| | - Dini Mawela
- Department of Paediatrics and Child Health, School of Medicine, Sefako Makgatho Health Sciences University, Gauteng, South Africa
| | - Masego Moncho
- Department of Medical Microbiology-National Health Laboratory Services, Sefako Makgatho Health Sciences University, Gauteng, South Africa
| | - Tonia Mphuthi
- Department of Pharmacy, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Ronald Nhari
- Department of Pharmacy, Life Springs Parkland Hospital, Johannesburg, South Africa
| | - Esmita Charani
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Pablo J Sánchez
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dena van den Bergh
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Flannery DD, Coggins SA, Medoro AK. Antibiotic Stewardship in the Neonatal Intensive Care Unit. J Intensive Care Med 2024:8850666241258386. [PMID: 38835250 DOI: 10.1177/08850666241258386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah A Coggins
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra K Medoro
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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7
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Mascarenhas D, Ho MSP, Ting J, Shah PS. Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis. Pediatrics 2024; 153:e2023065091. [PMID: 38766702 DOI: 10.1542/peds.2023-065091] [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: 12/01/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal sepsis is a significant contributor to mortality and morbidity; however, the uncontrolled use of antimicrobials is associated with significant adverse effects. Our objective with this article is to review the components of neonatal antimicrobial stewardship programs (ASP) and their effects on clinical outcomes, cost-effectiveness, and antimicrobial resistance. METHODS We selected randomized and nonrandomized trials and observational and quality improvement studies evaluating the impact of ASP with a cutoff date of May 22, 2023. The data sources for these studies included PubMed, Medline, Embase, Cochrane CENTRAL, Web of Science, and SCOPUS. Details of the ASP components and clinical outcomes were extracted into a predefined form. RESULTS Of the 4048 studies retrieved, 70 studies (44 cohort and 26 observational studies) of >350 000 neonates met the inclusion criteria. Moderate-certainty evidence reveals a significant reduction in antimicrobial initiation in NICU (pooled risk difference [RD] 19%; 95% confidence interval [CI] 14% to 24%; 21 studies, 27 075 infants) and combined NICU and postnatal ward settings (pooled RD 8%; 95% CI 6% to 10%; 12 studies, 358 317 infants), duration of antimicrobial agents therapy (pooled RD 20%; 95% CI 10% to 30%; 9 studies, 303 604 infants), length of therapy (pooled RD 1.82 days; 95% CI 1.09 to 2.56 days; 10 studies, 157 553 infants), and use of antimicrobial agents >5 days (pooled RD 9%; 95% CI 3% to 15%; 5 studies, 9412 infants). Low-certainty evidence reveals a reduction in economic burden and drug resistance, favorable sustainability metrices, without an increase in sepsis-related mortality or the reinitiation of antimicrobial agents. Studies had heterogeneity with significant variations in ASP interventions, population settings, and outcome definitions. CONCLUSIONS Moderate- to low-certainty evidence reveals that neonatal ASP interventions are associated with reduction in the initiation and duration of antimicrobial use, without an increase in adverse events.
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Affiliation(s)
- Dwayne Mascarenhas
- Neonatal-Perinatal Medicine Fellowship Training Program, University of Toronto, Toronto, Ontario
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
| | | | - Joseph Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Prakesh S Shah
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
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De Rose DU, Lapillonne A, Iacobelli S, Capolupo I, Dotta A, Salvatori G. Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot. Nutrients 2024; 16:1719. [PMID: 38892652 PMCID: PMC11174646 DOI: 10.3390/nu16111719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/22/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
The nutrition of preterm infants remains contaminated by wrong beliefs that reflect inexactitudes and perpetuate old practices. In this narrative review, we report current evidence in preterm neonates and in preterm neonates undergoing surgery. Convictions that necrotizing enterocolitis is reduced by the delay in introducing enteral feeding, a slow advancement in enteral feeds, and the systematic control of residual gastric volumes, should be abandoned. On the contrary, these practices prolong the time to reach full enteral feeding. The length of parenteral nutrition should be as short as possible to reduce the infectious risk. Intrauterine growth restriction, hemodynamic and respiratory instability, and patent ductus arteriosus should be considered in advancing enteral feeds, but they must not translate into prolonged fasting, which can be equally dangerous. Clinicians should also keep in mind the risk of refeeding syndrome in case of high amino acid intake and inadequate electrolyte supply, closely monitoring them. Conversely, when preterm infants undergo surgery, nutritional strategies are still based on retrospective studies and opinions rather than on randomized controlled trials. Finally, this review also highlights how the use of adequately fortified human milk is strongly recommended, as it offers unique benefits for immune and gastrointestinal health and neurodevelopmental outcomes.
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Affiliation(s)
- Domenico Umberto De Rose
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), Faculty of Medicine and Surgery, “Tor Vergata” University of Rome, 00133 Rome, Italy
| | - Alexandre Lapillonne
- Department of Neonatology, APHP, Necker-Enfants Malades University Hospital, EHU 7328 Paris Cite University Paris, 75015 Paris, France;
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX 77024, USA
| | - Silvia Iacobelli
- Réanimation Néonatale et Pédiatrique, Centre Hospitalier Universitaire Saint-Pierre, BP 350, 97448 Saint Pierre CEDEX, France;
- Centre d’Études Périnatales de l’Océan Indien (UR 7388), Université de La Réunion, BP 350, 97448 Saint Pierre CEDEX, France
| | - Irma Capolupo
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Andrea Dotta
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
| | - Guglielmo Salvatori
- Neonatal Intensive Care Unit, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy; (I.C.); (A.D.); (G.S.)
- Donor Human Milk Bank, “Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy
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9
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Soeorg H, Padari H, Ilmoja ML, Herodes K, Kipper K, Lutsar I, Metsvaht T. Prediction of C-reactive protein dynamics during meropenem treatment in neonates and infants. Br J Clin Pharmacol 2024; 90:801-811. [PMID: 37903648 DOI: 10.1111/bcp.15950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/01/2023] Open
Abstract
AIMS C-reactive protein (CRP) is used to determine the effect of antibiotic treatment on sepsis in neonates/infants. We aimed to develop pharmacokinetic-pharmacodynamic (PKPD) model of meropenem and CRP in neonates/infants and evaluate its predictive performance of CRP dynamics. METHODS Data from neonates/infants treated with meropenem in 3 previous studies were analysed. To the previously developed meropenem PK models, the addition of turnover, transit or effect compartment, delay differential equation PD models of CRP as a function of meropenem concentration or its cumulative area under the curve (AUC) were evaluated. The percentage of neonates/infants (P0.1 , P0.2 ) in whom the ratio of the fifth day CRP to its peak value was predicted with an error of <0.1 (<0.2) was calculated. RESULTS A total of 60 meropenem treatment episodes (median [range] gestational age 27.6 [22.6-40.9] weeks, postnatal age 13 [2-89] days) with a total of 351 CRP concentrations (maximum value 65.5 [13-358.4] mg/L) were included. Turnover model of CRP as a function of meropenem cumulative AUC provided the best fit and included CRP at the start of treatment, use of prior antibiotics, study and causative agent Staphylococcus aureus or enterococci as covariates. Using meropenem population predictions and data available at 0, 24, 48, 72 h after the start of treatment, P0.1 (P0.2 ) was 36.4, 36.4, 60.6 and 66.7% (70.0, 66.7, 72.7 and 78.7%), respectively. CONCLUSION The developed PKPD model of meropenem and CRP as a function of meropenem cumulative AUC incorporating several patient characteristics predicts CRP dynamics with an error of <0.2 in most neonates/infants.
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Affiliation(s)
- Hiie Soeorg
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Helgi Padari
- Pediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Mari-Liis Ilmoja
- Pediatric Intensive Care Unit, Tallinn Children's Hospital, Tallinn, Estonia
| | - Koit Herodes
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Microbiology, University of Tartu, Tartu, Estonia
- Pediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
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10
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[Clinical practice guidelines for meropenem therapy in neonatal sepsis (2024)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:107-117. [PMID: 38436306 PMCID: PMC10921874 DOI: 10.7499/j.issn.1008-8830.2309059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/29/2023] [Indexed: 03/05/2024]
Abstract
Meropenem is one of the most widely used special-grade antimicrobial agents in the treatment of neonatal sepsis. However, its irrational use has led to an increasingly severe problem of bacterial multidrug resistance. The guideline was developed following standardized methods and procedures, and provides 12 recommendations specifically addressing 9 clinical issues. The recommendations cover various aspects of meropenem use in neonates, including timing of administration, recommended dosage, extended infusion, monitoring and assessment, antimicrobial adjustment strategies, treatment duration, and treatment strategies for carbapenem-resistant Enterobacteriaceae infections. The aim of the guideline is to provide evidence-based recommendations and guidance for the rational use of meropenem in neonates with sepsis.
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11
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Patangia DV, Grimaud G, Wang S, Ross RP, Stanton C. Influence of age, socioeconomic status, and location on the infant gut resistome across populations. Gut Microbes 2024; 16:2297837. [PMID: 38217470 PMCID: PMC10793692 DOI: 10.1080/19490976.2023.2297837] [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: 06/12/2023] [Accepted: 12/18/2023] [Indexed: 01/15/2024] Open
Abstract
Antibiotic resistance is a growing global concern, with many ecological niches showing a high abundance of antibiotic resistance genes (ARGs), including the human gut. With increasing indications of ARGs in infants, this study aims to investigate the gut resistome profile during early life at a wider geographic level. To achieve this objective, we utilized stool samples data from 26 studies involving subjects aged up to 3 years from different geographical locations. The 32,277 Metagenome Assembled Genomes (MAGs) previously generated from shotgun sequencing reads from these studies were used for resistome analysis using RGI with the CARD database. This analysis showed that the distribution of ARGs across the countries in our study differed in alpha diversity and compositionally. In particular, the abundance of ARGs was found to vary by socioeconomic status and healthcare access and quality (HAQ) index. Surprisingly, countries having lower socioeconomic status and HAQ indices showed lower ARG abundance, which was contradictory to previous reports. Gram-negative genera, including Escherichia, Enterobacter, Citrobacter, and Klebsiella harbored a particularly rich set of ARGs, which included antibiotics that belong to the Reserve, Access or Watch category, such as glycopeptides, fluoroquinolones, sulfonamides, macrolides, and tetracyclines. We showed that ARG abundance exponentially decreased with time during the first 3 years of life. Many highly ARG-abundant species including Escherichia, Klebsiella, Citrobacter species that we observed are well-known pathobionts found in the infant gut in early life. High abundance of these species and a diverse range of ARGs in their genomes point toward the infant gut, acting as an ARG reservoir. This is a concern and further studies are needed to examine the causal effect and its consequences on long-term health.
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Affiliation(s)
- Dhrati V. Patangia
- School of Microbiology, University College Cork, Cork, Ireland
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, Cork, Ireland
| | - Ghjuvan Grimaud
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, Cork, Ireland
| | - Shaopu Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - R. Paul Ross
- School of Microbiology, University College Cork, Cork, Ireland
- APC Microbiome Ireland, Cork, Ireland
| | - Catherine Stanton
- Teagasc Food Research Centre, Moorepark, Fermoy, Co. Cork, Ireland
- APC Microbiome Ireland, Cork, Ireland
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12
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Regazzi M, Berardi A, Picone S, Tzialla C. Pharmacokinetic and Pharmacodynamic Considerations of Antibiotic Use in Neonates. Antibiotics (Basel) 2023; 12:1747. [PMID: 38136781 PMCID: PMC10740758 DOI: 10.3390/antibiotics12121747] [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: 11/13/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
The selection of an appropriate dose of a given antibiotic for a neonate not only requires knowledge of the drug's basic pharmacokinetic (PK) and pharmacodynamic (PD) properties but also the profound effects that organ development might have on the volume of distribution and clearance, both of which may affect the PK/PD of a drug. Interest has grown in alternative antibiotic dosing strategies that are better aligned with the antibiotic's PK and PD properties. These strategies should be used in conjunction with minimum inhibitory concentration measurements and therapeutic drug monitoring to measure their potential success. They can also guide the clinician in tailoring the delivery of antibiotics to suit an individual patient's needs. Model-informed precision dosing, such as Bayesian forecasting dosing software (which incorporates PK/PD population models), may be utilized to optimize antibiotic exposure in neonatal populations. Consequently, optimizing the antibiotic dose and exposure in each newborn requires expertise in different fields. It drives the collaboration of physicians together with lab technicians and quantitative clinical pharmacologists.
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Affiliation(s)
- Mario Regazzi
- S.I.F.E.B, Italian Society of Pharmacokinetics and Biopharmaceutics, 27100 Pavia, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy;
| | - Simonetta Picone
- Neonatology and Neonatal Intensive Care Unit, Policlinico Casilino, 00169 Rome, Italy;
| | - Chryssoula Tzialla
- Neonatal and Pediatric Unit, Ospedale Civile Voghera, ASST Pavia, 27100 Pavia, Italy;
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13
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Mthombeni TC, Burger JR, Lubbe MS, Julyan M. Antibiotic prescribing to inpatients in Limpopo, South Africa: a multicentre point-prevalence survey. Antimicrob Resist Infect Control 2023; 12:103. [PMID: 37717012 PMCID: PMC10505321 DOI: 10.1186/s13756-023-01306-z] [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: 06/03/2023] [Accepted: 09/11/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Electronic continuous surveillance databases are ideal for monitoring antibiotic use (ABU) in hospitalised patients for antibiotic stewardship programmes (ASP). However, such databases are scarce in low-resource settings. Point prevalence surveys (PPS) are viable alternatives. This report describes ABU and identifies ASP implementation improvement areas in Limpopo Province, South Africa. METHODS This cross-sectional descriptive study extracted patient-level ABU data from patients' files using a modified global PPS tool. Data were collected between September and November 2021 at five regional hospitals in Limpopo Province, South Africa. All patients in the wards before 8 a.m. on study days with an antibiotic prescription were included. Antibiotic use was stratified by Anatomic Therapeutic Chemical and Access, Watch, Reserve classifications and presented as frequencies and proportions with 95% confidence intervals (CI). Associations between categorical variables were assessed using the chi-square test. Cramér's V was used to assess the strength of these associations. RESULTS Of 804 inpatients surveyed, 261 (32.5%) (95% CI 29.2-35.7) were prescribed 416 antibiotics, 137 were female (52.5%) and 198 adults (75.9%). One hundred and twenty-two (46.7%) patients received one antibiotic, 47.5% (124/261) received two, and 5.7% (15/261) received three or more antibiotics. The intensive care units had a higher ABU (68.6%, 35/51) compared to medical (31.3%, 120/384) and surgical (28.5%, 105/369) wards (p = 0.005, Cramér's V = 0.2). Lower respiratory tract infection (27.4%, 104/379), skin and soft tissue infections (SST) (23.5%, 89/379), and obstetrics and gynaecology prophylaxis (14.0%, 53/379) were the common diagnoses for antibiotic prescriptions. The three most prescribed antibiotic classes were imidazoles (21.9%, 91/416), third-generation cephalosporins (20.7%, 86/416) and combination penicillin (18.5%, 79/416). Access antibiotics accounted for 70.2% (292/416) of prescriptions and Watch antibiotics for 29.6% (123/416) (p = 0.110, Cramér's V = 0.1). Reasons for prescribing and treatment plans were documented in 64.9% (270/416) (95% CI 60.3-69.5) and 21.4% (89/416) (95% CI 17.3-25.3) of prescriptions, respectively. CONCLUSIONS The study serves as a baseline for ABU surveillance at the five regional hospitals in Limpopo Province. Lack of documentation indicates poor prescribing practices; ASP should address gaps by deploying evidence-based, multifaceted and stepwise interventions.
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Affiliation(s)
- Tiyani Comfort Mthombeni
- Medicine Usage in South Africa (MUSA), North-West University Potchefstroom Campus, Potchefstroom, South Africa
| | - Johanita Riétte Burger
- Medicine Usage in South Africa (MUSA), North-West University Potchefstroom Campus, Potchefstroom, South Africa.
| | - Martha Susanna Lubbe
- Medicine Usage in South Africa (MUSA), North-West University Potchefstroom Campus, Potchefstroom, South Africa
| | - Marlene Julyan
- Medicine Usage in South Africa (MUSA), North-West University Potchefstroom Campus, Potchefstroom, South Africa
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14
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Lewald ZS, Prusakov P, Magers JK, Kielt MJ, de Alba Romero C, White NO, Miller RR, Moraille R, Theile AR, Sánchez PJ. Short-course antibiotic therapy for pneumonia in the neonatal intensive care unit. J Perinatol 2023; 43:1145-1151. [PMID: 37438484 DOI: 10.1038/s41372-023-01720-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To determine the adherence and safety outcomes of a 5-day antibiotic course with a "time-out" for treatment of "blood culture-negative" pneumonia in the NICU. STUDY DESIGN Prospective surveillance of all infants diagnosed with pneumonia at 7 NICUs from 8/2020-12/2021. Safety outcomes were defined a priori by re-initiation of antibiotic therapy within 14 days after discontinuation and overall and sepsis-related mortality. RESULTS 128 infants were diagnosed with 136 episodes of pneumonia; 88% (n = 119) were treated with 5 days of definitive antibiotic therapy. Antibiotics were restarted within 14 days in 22 (16%) of the 136 pneumonia episodes. However, only 3 (3%) of the 119 episodes of pneumonia treated for 5 days had antibiotics restarted for pneumonia. Mortality was 5% (7/128); 5 of the 7 deaths were assessed as sepsis-related. CONCLUSION Adherence to the 5-day definitive antibiotic treatment for "culture-negative" pneumonia was high and the intervention seemed safe.
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Affiliation(s)
- Zachery S Lewald
- The Ohio State University, Columbus, OH, USA
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Pavel Prusakov
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Matthew J Kielt
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Concepción de Alba Romero
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | | | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Chetty T, Pillay A, Balakrishna Y, Reddy T, Goga A, Moore DP, Karsas M, Cloete J, Archary M, Kwawegen AV, Thomas R, Nakwa FL, Waggie Z, Magrath S, Jeena P. Healthcare-Associated Infections Drive Antimicrobial Prescribing in Pediatric Departments at Three Academic Hospitals in South Africa. Pediatr Infect Dis J 2023; Publish Ahead of Print:00006454-990000000-00494. [PMID: 37368998 DOI: 10.1097/inf.0000000000003954] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND The prevalence of antimicrobial prescriptions for healthcare-associated infections (HAI) in South Africa is largely unknown. This study aimed to estimate the point prevalence of pediatric antibiotic and antifungal usage in 3 South African academic hospitals. METHODS This cross-sectional study included hospitalized neonates and children (0-15 years). We used the World Health Organization methodology for antimicrobial point prevalence studies, with weekly surveys to achieve a sample size of ~400 at each site. RESULTS Overall, 1,946 antimicrobials were prescribed to 1,191 patients. At least 1 antimicrobial was prescribed for 22.9% [95% confidence interval (CI): 15.5-32.5%] of patients. The prevalence of antimicrobial prescribing for HAI was 45.6%. In the multivariable analysis, relative to children 6-12 years, neonates [adjusted relative risk (aRR): 1.64; 95% CI: 1.06-2.53], infants (aRR: 1.57; 95% CI: 1.12-2.21) and adolescents (aRR: 2.18; 95% CI: 1.45-3.29) had significantly increased risk of prescriptions for HAI. Being preterm (aRR: 1.33; 95% CI: 1.04-1.70) and underweight (aRR: 1.25; 95% CI: 1.01-1.54) was predictive of antimicrobial usage for HAI. Having an indwelling device, surgery since admission, blood transfusions and classification as rapidly fatal on McCabe score also increased the risk of prescriptions for HAI. CONCLUSIONS The high prevalence of antimicrobial prescribing for HAI to treat children with recognized risk factors in academic hospitals in South Africa is concerning. Concerted efforts need to be made to strengthen hospital-level infection prevention and control measures, with a critical review of antimicrobial usage through functional antibiotic stewardship programs to preserve the available antimicrobial armamentarium at the hospital level.
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Affiliation(s)
- Terusha Chetty
- From the HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, South Africa
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ashendri Pillay
- Department of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Yusentha Balakrishna
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
| | - Tarylee Reddy
- Biostatistics Research Unit, South African Medical Research Council, Durban, South Africa
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa
| | - Ameena Goga
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Pediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - David P Moore
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- South African Medical Research Council Vaccine and Infectious Diseases Analytics (VIDA) Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Maria Karsas
- Department of Pediatrics and Child Health, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Jeané Cloete
- Maternal and Infant Health Care Strategies Research Unit Centre, University of Pretoria, Pretoria, South Africa
| | - Moherndran Archary
- Department of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
| | - Alison van Kwawegen
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Reenu Thomas
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Firdose Lambey Nakwa
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Zainab Waggie
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie Magrath
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Prakash Jeena
- Department of Pediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
- Department of Pediatrics and Child Health, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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16
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Hajjar N, Ting JY, Shah PS, Lee KS, Dunn MS, Srigley JA, Khurshid F. Blood culture collection practices in NICU; A national survey. Paediatr Child Health 2023; 28:166-171. [PMID: 37205138 PMCID: PMC10186103 DOI: 10.1093/pch/pxac112] [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: 06/08/2022] [Accepted: 10/23/2022] [Indexed: 03/17/2024] Open
Abstract
Background Sepsis is the leading cause of mortality and morbidity in neonates. Blood cultures are the gold standard in diagnosing neonatal sepsis; however, there are currently no consensus guidelines for blood culture collection in neonates and significant practice variation exists in Neonatal Intensive Care Units (NICUs) globally. Objective To examine current practices in obtaining blood cultures in the evaluation of neonatal sepsis in NICUs across Canada. Methods A nine-item electronic survey was sent to each of the 29 level-3 NICUs in Canada, which are equipped to provide highly specialized care for newborns. Results Responses were received from 90% (26/29) of sites. Sixty-five percent (17/26) of sites have blood culture collection guidelines for the investigation of neonatal sepsis. Forty-eight percent (12/25) of sites routinely target 1.0 mL per culture bottle. In late-onset sepsis (LOS), 58% (15/26) of sites process one aerobic culture bottle, whereas four sites routinely add anaerobic culture bottles. In early-onset sepsis (EOS) in very low birth weight infants (BW <1.5 kg), 73% (19/26) of sites use umbilical cord blood, and 72% (18/25) use peripheral venipuncture. Two sites routinely collect cord blood for culture in EOS. Only one site applies the concept of differential time-to-positivity to diagnose central-line-associated bloodstream infection. Conclusions There is significant practice variation in methods used to obtain blood cultures in level-3 NICUs across Canada. Standardization of blood culture collection practices can provide reliable estimates of the true incidence of neonatal sepsis and help to develop appropriate antimicrobial stewardship strategies.
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Affiliation(s)
- Nicole Hajjar
- Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael S Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jocelyn A Srigley
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Faiza Khurshid
- Department of Pediatrics, Queen’s University, Kingston, Ontario, Canada
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17
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Pantoja A, Sveum S, Frost S, Duran A, Burks J, Schernecke C, Feinberg M. New strategies to Reduce Unnecessary Antibiotic Use in the NICU: A Quality Improvement Initiative. Pediatr Qual Saf 2023; 8:e659. [PMID: 38571732 PMCID: PMC10990351 DOI: 10.1097/pq9.0000000000000659] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/05/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Early-onset sepsis (EOS) and late-onset Sepsis (LOS) are common diagnoses entertained in sick newborns treated in neonatal intensive care units (NICUs), and antibiotics are the medications most prescribed in NICUs. Antibiotic stewardship programs have an important impact on limiting unnecessary antibiotic use. Methods Following the Model for Improvement, between 2/1/16 and 1/31/17, at a level 3 NICU, a multidisciplinary team implemented PDSA cycles to promote antibiotic stewardship practices for newborns at risk of EOS and LOS. The main goal was to decrease the antibiotic usage rate (AUR) safely. Primary strategies included discontinuing antibiotics within 24 hours of life if the newborn was stable, and the blood culture was negative for EOS and implementing an "antibiotic time-out" during rounds. Results For all newborns admitted to our NICU, the AUR decreased, for EOS from 137 to 32 days per 1000 patient days (77% reduction) and for LOS from 277 to 121 days per 1000 patient days (56% reduction). We demonstrated the sustainability of both EOS-AUR and LOS-AUR during the 2 years postcompletion of the intervention period. There were no adverse effects of reducing the AUR. Conclusion Interventions that reduce unnecessary antibiotic use in the NICU are safe and prevent excessive antibiotic exposure.
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Affiliation(s)
- Alfonso Pantoja
- From the Saint Joseph Hospital, Denver, Colo
- Colorado Permanente Medical Group, Denver, CO
| | - Scott Sveum
- From the Saint Joseph Hospital, Denver, Colo
- Vail Health, Frisco, CO
| | | | | | - Jeanne Burks
- From the Saint Joseph Hospital, Denver, Colo
- Envision Physician Services, Phoenix, AZ
| | - Christi Schernecke
- From the Saint Joseph Hospital, Denver, Colo
- Methodist Dallas Medical Center, Dallas TX
| | - Michelle Feinberg
- From the Saint Joseph Hospital, Denver, Colo
- Colorado Permanente Medical Group, Denver, CO
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18
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Developmental Pharmacokinetics of Antibiotics Used in Neonatal ICU: Focus on Preterm Infants. Biomedicines 2023; 11:biomedicines11030940. [PMID: 36979919 PMCID: PMC10046592 DOI: 10.3390/biomedicines11030940] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023] Open
Abstract
Neonatal Infections are among the most common reasons for admission to the intensive care unit. Neonatal sepsis (NS) significantly contributes to mortality rates. Empiric antibiotic therapy of NS recommended by current international guidelines includes benzylpenicillin, ampicillin/amoxicillin, and aminoglycosides (gentamicin). The rise of antibacterial resistance precipitates the growth of the use of antibiotics of the Watch (second, third, and fourth generations of cephalosporines, carbapenems, macrolides, glycopeptides, rifamycins, fluoroquinolones) and Reserve groups (fifth generation of cephalosporines, oxazolidinones, lipoglycopeptides, fosfomycin), which are associated with a less clinical experience and higher risks of toxic reactions. A proper dosing regimen is essential for effective and safe antibiotic therapy, but its choice in neonates is complicated with high variability in the maturation of organ systems affecting drug absorption, distribution, metabolism, and excretion. Changes in antibiotic pharmacokinetic parameters result in altered efficacy and safety. Population pharmacokinetics can help to prognosis outcomes of antibiotic therapy, but it should be considered that the neonatal population is heterogeneous, and this heterogeneity is mainly determined by gestational and postnatal age. Preterm neonates are common in clinical practice, and due to the different physiology compared to the full terms, constitute a specific neonatal subpopulation. The objective of this review is to summarize the evidence about the developmental changes (specific for preterm and full-term infants, separately) of pharmacokinetic parameters of antibiotics used in neonatal intensive care units.
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19
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Ou-Yang MC, Hsu JF, Chu SM, Chang CM, Chen CC, Huang HR, Yang PH, Fu RH, Tsai MH. Influences of Initial Empiric Antibiotics with Ampicillin plus Cefotaxime on the Outcomes of Neonates with Respiratory Failure: A Propensity Score Matched Analysis. Antibiotics (Basel) 2023; 12:antibiotics12030445. [PMID: 36978311 PMCID: PMC10044461 DOI: 10.3390/antibiotics12030445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47–118.8] days versus 78 [45.0–106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes.
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Affiliation(s)
- Mei-Chen Ou-Yang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Jen-Fu Hsu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shih-Ming Chu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ching-Min Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Pediatric Gastrointestinal Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Chih-Chen Chen
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Hsuan-Rong Huang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Peng-Hong Yang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Pediatric Gastrointestinal Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Ren-Huei Fu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Horng Tsai
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
- Correspondence: ; Tel.:+886-5-691-5151 (ext. 2878); Fax: +886-5-691-3222
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20
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Maalouf FI, Saad T, Zakhour R, Yunis K. Successful establishment and five-year sustainability of a neonatal-specific antimicrobial stewardship program in a low middle-income country. Front Pharmacol 2023; 13:1076392. [PMID: 36686698 PMCID: PMC9848584 DOI: 10.3389/fphar.2022.1076392] [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: 10/21/2022] [Accepted: 12/15/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction: Antibiotic use varies substantially among neonatal intensive care units (NICUs) without any appreciable impact on outcomes. An increased use of antimicrobials has been reported in low-middle income countries. This raises the concern for potential overuse of antibiotics in a fragile patient population, thus increasing the rates of multidrug resistant organisms and affecting the developing microbiome. The presence of a neonatal-specific antimicrobial stewardship program can aid with the judicious use of antibiotics in the neonatal population and thus decrease the overuse of such medications. Methods: In this quality improvement project, we established and implemented a neonatal-specific antimicrobial stewardship program with the aim of reducing antimicrobial use in the neonatal intensive care units within a year of starting. Several interventions using a multidisciplinary approach included implementing standard algorithms, direct audit and feedback, and automated hard stops. Results: These series of interventions led to a 35% decrease in antimicrobial usage in the first 3 months and further decrease was seen with a median of 63% decline for a total of 5 years after project implementation. The use of the most commonly prescribed antibiotics, ampicillin and gentamicin, decreased by 63% and 79%, respectively. There was no evidence that this change in practice affected or jeopardized patient outcomes. Additionally, it showed sustainability and resilience despite the many challenges such as COVID-19 pandemic, political and financial unrest, and healthcare sector collapse. Discussion: This model-based and multidisciplinary low-cost approach can lead to marked improvement affecting neonatal outcomes and can be replicated in other similar centers.
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Affiliation(s)
- Faouzi I Maalouf
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Therese Saad
- Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ramia Zakhour
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Khalid Yunis
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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21
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Ren Z, Yang S, Han J, Nie C, Wang C, Wang J, Zheng X, Yang H, Zhang Q, Pei J, Xu F, Yang J. Reduction of antibiotic use and multi-drug resistance bacteria infection in neonates after improvement of antibiotics use strategy in a level 4 neonatal intensive care unit in southern China. Eur J Clin Microbiol Infect Dis 2023; 42:87-98. [PMID: 36409375 DOI: 10.1007/s10096-022-04522-4] [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: 08/31/2022] [Accepted: 11/04/2022] [Indexed: 11/22/2022]
Abstract
The investigation on antibiotic stewardship in neonatal intensive care unit in China is scarce. This study aimed to analyze the effect of a comprehensive 2-year antibiotic stewardship in a level 4 NICU. During this baseline period from October 1st 2017 to October 1st 2019, continuation of empirical antibiotic therapy for ruled-out sepsis courses was beyond 72 h and for pneumonia was more than 7 days. Meropenem or vancomycin was used even if they were not the only bacterial sensitive antibiotics. The intervention period was from October 2nd 2019 to August 23rd 2021. Three areas for quality improvement were targeted in our center: discontinuation of antibiotic use in ruled-out sepsis within 72 h, treatment duration for culture-negative pneumonia less than 7 days, and vancomycin or meropenem was not used unless the cultured bacteria was only susceptible to them. The total antibiotic consumption decreased from 791.1 to 466.3 days of therapy per 1000 patient days from baseline to intervention period. Antibiotics were stopped within 72 h for 47.48% patients with rule-out sepsis and within 7 days for 75.70% patients with pneumonia compared with 11.56% and 37.69% during the baseline period respectively. The prevalence of multi-drug resistance bacteria decreased from 67.20 to 48.90%. The total use rate of meropenem or vancomycin decreased from 7.6 to 1.8%. Our quality improvement approach on antibiotic strategy significantly reduced antibiotic use and prevalence of multi-drug resistance bacteria in our NICU.
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Affiliation(s)
- Zhuxiao Ren
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China.,Guangdong Neonatal ICU Medical Quality Control Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Shumei Yang
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China.,Guangdong Neonatal ICU Medical Quality Control Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jiangxue Han
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China
| | - Chuan Nie
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China.,Guangdong Neonatal ICU Medical Quality Control Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Cuicui Wang
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jianlan Wang
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China
| | - Xuaner Zheng
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China
| | - Haoming Yang
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China
| | - Qi Zhang
- Department of Clinical Genetic Center, Guangdong Women and Children Hospital, Guangzhou, China
| | - Jingjun Pei
- Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fang Xu
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China. .,Guangdong Neonatal ICU Medical Quality Control Center, Guangdong Women and Children Hospital, Guangzhou, China.
| | - Jie Yang
- Department of Neonatology, National Medical Discipline Priority, Guangdong Women and Children Hospital, Guangzhou, China. .,Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
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22
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Saleem Z, Godman B, Cook A, Khan MA, Campbell SM, Seaton RA, Siachalinga L, Haseeb A, Amir A, Kurdi A, Mwita JC, Sefah IA, Opanga SA, Fadare JO, Ogunleye OO, Meyer JC, Massele A, Kibuule D, Kalungia AC, Shahwan M, Nabayiga H, Pichierri G, Moore CE. Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future. Antibiotics (Basel) 2022; 11:1824. [PMID: 36551481 PMCID: PMC9774141 DOI: 10.3390/antibiotics11121824] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
There are serious concerns with rising antimicrobial resistance (AMR) across countries increasing morbidity, mortality and costs. These concerns have resulted in a plethora of initiatives globally and nationally including national action plans (NAPs) to reduce AMR. Africa is no exception, especially with the highest rates of AMR globally. Key activities in NAPs include gaining a greater understanding of current antimicrobial utilization patterns through point prevalence surveys (PPS) and subsequently instigating antimicrobial stewardship programs (ASPs). Consequently, there is a need to comprehensively document current utilization patterns among hospitals across Africa coupled with ASP studies. In total, 33 PPS studies ranging from single up to 18 hospitals were documented from a narrative review with typically over 50% of in-patients prescribed antimicrobials, up to 97.6% in Nigeria. The penicillins, ceftriaxone and metronidazole, were the most prescribed antibiotics. Appreciable extended prescribing of antibiotics up to 6 days or more post-operatively was seen across Africa to prevent surgical site infections. At least 19 ASPs have been instigated across Africa in recent years to improve future prescribing utilizing a range of prescribing indicators. The various findings resulted in a range of suggested activities that key stakeholders, including governments and healthcare professionals, should undertake in the short, medium and long term to improve future antimicrobial prescribing and reduce AMR across Africa.
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Affiliation(s)
- Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan 60800, Pakistan
| | - Brian Godman
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman 346, United Arab Emirates
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX1 2JD, UK
| | | | - Stephen M. Campbell
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Ronald Andrew Seaton
- Queen Elizabeth University Hospital, Govan Road, Glasgow G51 4TF, UK
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, 50 West Nile Street, Glasgow G1 2NP, UK
| | - Linda Siachalinga
- College of Pharmacy, Yeungnam University, Daehak-Ro, Gyeongsan, Gyeongbuk 38541, Republic of Korea
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia
| | - Afreenish Amir
- Department of Microbiology, Armed Forces Institute of Pathology, National University of Medical Sciences, Rawalpindi 46000, Pakistan
| | - Amanj Kurdi
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil 44001, Iraq
- Center of Research and Strategic Studies, Lebanese French University, Erbil 44001, Iraq
| | - Julius C. Mwita
- Department of Internal Medicine, Faculty of Medicine, University of Botswana, Private Bag 0713 UB, Gaborone 00704, Botswana
| | - Israel Abebrese Sefah
- Pharmacy Practice Department, School of Pharmacy, University of Health and Allied Sciences, Volta Region, Hohoe PMB 31, Ghana
| | - Sylvia A. Opanga
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi P.O. Box 19676-00202, Kenya
| | - Joseph O. Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado Ekiti 362103, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital, Ado Ekiti 360211, Nigeria
| | - Olayinka O. Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Ikeja, Lagos 100271, Nigeria
- Department of Medicine, Lagos State University Teaching Hospital, Ikeja 100271, Nigeria
| | - Johanna C. Meyer
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
- South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
| | - Amos Massele
- Department of Clinical Pharmacology and Therapeutics, Hurbert Kairuki Memorial University, 70 Chwaku Road Mikocheni, Dar Es Salaam P.O. Box 65300, Tanzania
| | - Dan Kibuule
- Department of Pharmacology & Therapeutics, Busitema University, Mbale P.O. Box 236, Uganda
| | - Aubrey C. Kalungia
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Moyad Shahwan
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman 346, United Arab Emirates
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman 346, United Arab Emirates
| | - Hellen Nabayiga
- Management Science Department, Strathclyde Business School, University of Strathclyde, 199 Cathedral Street, Glasgow G4 0QU, UK
| | - Giuseppe Pichierri
- Microbiology Department, Torbay and South Devon Foundation Trust, Lowes Bridge Torbay Hospital, Torquay TQ2 7AA, UK
| | - Catrin E. Moore
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
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23
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Giannoni E, Dimopoulou V, Klingenberg C, Navér L, Nordberg V, Berardi A, el Helou S, Fusch G, Bliss JM, Lehnick D, Guerina N, Seliga-Siwecka J, Maton P, Lagae D, Mari J, Janota J, Agyeman PKA, Pfister R, Latorre G, Maffei G, Laforgia N, Mózes E, Størdal K, Strunk T, Stocker M. Analysis of Antibiotic Exposure and Early-Onset Neonatal Sepsis in Europe, North America, and Australia. JAMA Netw Open 2022; 5:e2243691. [PMID: 36416819 PMCID: PMC9685486 DOI: 10.1001/jamanetworkopen.2022.43691] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Appropriate use of antibiotics is life-saving in neonatal early-onset sepsis (EOS), but overuse of antibiotics is associated with antimicrobial resistance and long-term adverse outcomes. Large international studies quantifying early-life antibiotic exposure along with EOS incidence are needed to provide a basis for future interventions aimed at safely reducing neonatal antibiotic exposure. OBJECTIVE To compare early postnatal exposure to antibiotics, incidence of EOS, and mortality among different networks in high-income countries. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective, cross-sectional study of late-preterm and full-term neonates born between January 1, 2014, and December 31, 2018, in 13 hospital-based or population-based networks from 11 countries in Europe and North America and Australia. The study included all infants born alive at a gestational age greater than or equal to 34 weeks in the participating networks. Data were analyzed from October 2021 to March 2022. EXPOSURES Exposure to antibiotics started in the first postnatal week. MAIN OUTCOMES AND MEASURES The main outcomes were the proportion of late-preterm and full-term neonates receiving intravenous antibiotics, the duration of antibiotic treatment, the incidence of culture-proven EOS, and all-cause and EOS-associated mortality. RESULTS A total of 757 979 late-preterm and full-term neonates were born in the participating networks during the study period; 21 703 neonates (2.86%; 95% CI, 2.83%-2.90%), including 12 886 boys (59.4%) with a median (IQR) gestational age of 39 (36-40) weeks and median (IQR) birth weight of 3250 (2750-3750) g, received intravenous antibiotics during the first postnatal week. The proportion of neonates started on antibiotics ranged from 1.18% to 12.45% among networks. The median (IQR) duration of treatment was 9 (7-14) days for neonates with EOS and 4 (3-6) days for those without EOS. This led to an antibiotic exposure of 135 days per 1000 live births (range across networks, 54-491 days per 1000 live births). The incidence of EOS was 0.49 cases per 1000 live births (range, 0.18-1.45 cases per 1000 live births). EOS-associated mortality was 3.20% (12 of 375 neonates; range, 0.00%-12.00%). For each case of EOS, 58 neonates were started on antibiotics and 273 antibiotic days were administered. CONCLUSIONS AND RELEVANCE The findings of this study suggest that antibiotic exposure during the first postnatal week is disproportionate compared with the burden of EOS and that there are wide (up to 9-fold) variations internationally. This study defined a set of indicators reporting on both dimensions to facilitate benchmarking and future interventions aimed at safely reducing antibiotic exposure in early life.
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Affiliation(s)
- Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Varvara Dimopoulou
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Lars Navér
- Department of Neonatology, Karolinska University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Viveka Nordberg
- Department of Neonatology, Karolinska University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Alberto Berardi
- Neonatal Intensive Care Unit, Mother and Child Department, Policlinico University Hospital, Modena, Italy
| | - Salhab el Helou
- Division of Neonatology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gerhard Fusch
- Division of Neonatology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Joseph M. Bliss
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence
| | - Dirk Lehnick
- Biostatistics and Methodology, CTU-CS, Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Nicholas Guerina
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Warren Alpert Medical School of Brown University, Providence
| | - Joanna Seliga-Siwecka
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Pierre Maton
- Service Néonatal, Clinique CHC-Montlegia, Groupe Santé CHC, Liège, Belgium
| | - Donatienne Lagae
- Neonatology and Neonatal Intensive Care Unit, CHIREC-Delta Hospital, Brussels, Belgium
| | - Judit Mari
- Department of Paediatrics, University of Szeged, Szeged, Hungary
| | - Jan Janota
- Neonatal Unit, Department of Obstetrics and Gynecology, Motol University Hospital Prague, Prague, Czech Republic
- Department of Pathological Physiology, 1st Medical School, Charles University Prague, Prague, Czech Republic
- Department of Neonatology, Thomayer University Hospital Prague, Prague, Czech Republic
| | - Philipp K. A. Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Riccardo Pfister
- Neonatology and Paediatric Intensive Care Unit, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Giuseppe Latorre
- Neonatology and Neonatal Intensive Care Unit, Ecclesiastical General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Gianfranco Maffei
- Neonatology and Neonatal Intensive Care Unit, Policlinico Riuniti Foggia, Foggia, Italy
| | - Nicola Laforgia
- Neonatologia e Terapia Intensiva Neonatale, University of Bari, Bari, Italy
| | - Enikő Mózes
- Perinatal Intensive Care Unit, Department of Obstetrics and Gynaecology, Semmelweis University, Budapest, Hungary
| | - Ketil Størdal
- Institute of Clinical Medicine, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Tobias Strunk
- Neonatal Directorate, Child and Adolescent Health Service, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Martin Stocker
- Department of Pediatrics, Children’s Hospital Lucerne, Lucerne, Switzerland
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Kitt E, Hayes M, Congdon M, Ballester L, Sewawa KB, Mulale U, Mazhani L, Arscott-Mills T, Steenhoff A, Coffin S. Risk factors for mortality in a hospitalised neonatal cohort in Botswana. BMJ Open 2022; 12:e062776. [PMID: 36691117 PMCID: PMC9454043 DOI: 10.1136/bmjopen-2022-062776] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/24/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES A disproportionate number of neonatal deaths occur in low/middle-income countries, with sepsis a leading contributor of mortality. In this study, we investigate risk factors for mortality in a cohort of high-risk hospitalised neonates in Botswana. Independent predictors for mortality for infants experiencing either a sepsis or a non-sepsis-related death are described. METHODS This is a prospective observational cohort study with infants enrolled from July to October 2018 at the neonatal unit (NNU) of Princess Marina Hospital (PMH) in Gaborone, Botswana. Data on demographic, clinical and unit-specific variables were obtained. Neonates were followed to death or discharge, including transfer to another hospital. Death was determined to be infectious versus non-infectious based on primary diagnosis listed on day of death by lead clinician on duty. RESULTS Our full cohort consisted of 229 patients. The overall death rate was 227 per 1000 live births, with cumulative proportion of deaths of 22.7% (n=47). Univariate analysis revealed that sepsis, extremely low birth weight (ELBW) status, hypoxic ischaemic encephalopathy, critical illness and infants born at home were associated with an increased risk of all-cause mortality. Our multivariate model revealed that critical illness (HR 3.07, 95% CI 1.56 to 6.03) and being born at home (HR 4.82, 95% CI 1.76 to 13.19) were independently associated with all-cause mortality. Low birth weight status was independently associated with a decreased risk of mortality (HR 0.24, 95% CI 0.11 to 0.53). There was a high burden of infection in the cohort with more than half of infants (140, 61.14%) diagnosed with sepsis at least once during their NNU admission. Approximately 20% (n=25) of infants with sepsis died before discharge. Our univariate subanalysis of the sepsis cohort revealed that ELBW and critical illness were associated with an increased risk of death. These findings persisted in the multivariate model with HR 3.60 (95% CI 1.11 to 11.71) and HR 2.39 (95% CI 1 to 5.77), respectively. CONCLUSIONS High rates of neonatal mortality were noted. Urgent interventions are needed to improve survival rates at PMH NNU and to prioritise care for critically ill infants at time of NNU admission, particularly those born at home and/or of ELBW.
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Affiliation(s)
- Eimear Kitt
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Hayes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan Congdon
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Section of Hospital Medicine, CHOP, Philadelphia, Pennsylvania, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kgotlaetsile B Sewawa
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Unami Mulale
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Loeto Mazhani
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Tonya Arscott-Mills
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew Steenhoff
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan Coffin
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Guitor AK, Yousuf EI, Raphenya AR, Hutton EK, Morrison KM, McArthur AG, Wright GD, Stearns JC. Capturing the antibiotic resistome of preterm infants reveals new benefits of probiotic supplementation. MICROBIOME 2022; 10:136. [PMID: 36008821 PMCID: PMC9414150 DOI: 10.1186/s40168-022-01327-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/14/2022] [Indexed: 05/28/2023]
Abstract
BACKGROUND Probiotic use in preterm infants can mitigate the impact of antibiotic exposure and reduce rates of certain illnesses; however, the benefit on the gut resistome, the collection of antibiotic resistance genes, requires further investigation. We hypothesized that probiotic supplementation of early preterm infants (born < 32-week gestation) while in hospital reduces the prevalence of antibiotic resistance genes associated with pathogenic bacteria in the gut. We used a targeted capture approach to compare the resistome from stool samples collected at the term corrected age of 40 weeks for two groups of preterm infants (those that routinely received a multi-strain probiotic during hospitalization and those that did not) with samples from full-term infants at 10 days of age to identify if preterm birth or probiotic supplementation impacted the resistome. We also compared the two groups of preterm infants up to 5 months of age to identify persistent antibiotic resistance genes. RESULTS At the term corrected age, or 10 days of age for the full-term infants, we found over 80 antibiotic resistance genes in the preterm infants that did not receive probiotics that were not identified in either the full-term or probiotic-supplemented preterm infants. More genes associated with antibiotic inactivation mechanisms were identified in preterm infants unexposed to probiotics at this collection time-point compared to the other infants. We further linked these genes to mobile genetic elements and Enterobacteriaceae, which were also abundant in their gut microbiomes. Various genes associated with aminoglycoside and beta-lactam resistance, commonly found in pathogenic bacteria, were retained for up to 5 months in the preterm infants that did not receive probiotics. CONCLUSIONS This pilot survey of preterm infants shows that probiotics administered after preterm birth during hospitalization reduced the diversity and prevented persistence of antibiotic resistance genes in the gut microbiome. The benefits of probiotic use on the microbiome and the resistome should be further explored in larger groups of infants. Due to its high sensitivity and lower sequencing cost, our targeted capture approach can facilitate these surveys to further address the implications of resistance genes persisting into infancy without the need for large-scale metagenomic sequencing. Video Abstract.
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Affiliation(s)
- Allison K Guitor
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Efrah I Yousuf
- Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Amogelang R Raphenya
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Eileen K Hutton
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada
| | - Katherine M Morrison
- Department of Pediatrics, McMaster University, Hamilton, Canada
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada
| | - Andrew G McArthur
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Gerard D Wright
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Canada
- David Braley Centre for Antibiotic Discovery, McMaster University, Hamilton, Canada
| | - Jennifer C Stearns
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.
- The Baby & Mi and the Baby & Pre-Mi Cohort Studies, Hamilton, Canada.
- Department of Medicine, McMaster University, Hamilton, Canada.
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Canada.
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Antimicrobial Utilization among Neonates and Children: A Multicenter Point Prevalence Study from Leading Children’s Hospitals in Punjab, Pakistan. Antibiotics (Basel) 2022; 11:antibiotics11081056. [PMID: 36009925 PMCID: PMC9405424 DOI: 10.3390/antibiotics11081056] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 01/25/2023] Open
Abstract
Antimicrobial resistance (AMR) compromises global health due to the associated morbidity, mortality, and costs. The inappropriate use of antimicrobial agents is a prime driver of AMR. Consequently, it is imperative to gain a greater understanding of current utilization patterns especially in high-risk groups including neonates and children. A point prevalence survey (PPS) was conducted among three tertiary care children’s hospitals in the Punjab province using the World Health Organization (WHO) methodology. Antibiotic use was documented according to the WHO AWaRe classification. Out of a total of 1576 neonates and children, 1506 were prescribed antibiotics on the day of the survey (prevalence = 95.5%), with an average of 1.9 antibiotics per patient. The majority of antibiotics were prescribed in the medical ward (75%), followed by surgical ward (12.8%). Furthermore, 56% of antibiotics were prescribed prophylactically, with most of the antibiotics (92.3%) administered via the parenteral route. The top three indications for antibiotics were respiratory tract infections (34.8%), gastrointestinal infections (15.8%), and prophylaxis for medical problems (14.3%). The three most common antibiotics prescribed were ceftriaxone (25.8%), amikacin (9.2%), and vancomycin (7.9%). Overall, 76.6% of the prescribed antibiotics were from Watch category followed by 21.6% from the Access group. There was a very high prevalence of antibiotic use among hospitalized neonates and children in this study. Urgent measures are needed to engage all the stakeholders to formulate effective ASPs in Pakistan, especially surrounding Watch antibiotics.
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Martini S, Vitali F, Capelli I, Donadei C, Raschi E, Aiello V, Corvaglia L, De Ponti F, Poluzzi E, Galletti S. Impact of nephrotoxic drugs on urinary biomarkers of renal function in very preterm infants. Pediatr Res 2022; 91:1715-1722. [PMID: 34897282 DOI: 10.1038/s41390-021-01905-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/01/2021] [Accepted: 11/26/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Following preterm birth, the immature kidney is exposed to several harmful conditions, with an increased risk of renal impairment. We aimed to assess urinary biomarkers of renal function in very preterm infants during early nephrotoxic treatments. METHODS Infants ≤32 weeks' gestation and ≤1500 g were enrolled in this observational prospective study. Urine samples were collected on day 1(T1), 2-4(T2), 5-7(T3), 8-10(T4), 11-13(T5). The following urinary biomarkers were determined: osteopontin (uOPN), epidermal growth factor (uEGF), neutrophil gelatinase-associated lipocalin (uNGAL), cystatin C (uCysC). The infants were grouped according to their exposure to amikacin or ibuprofen during the study period and a between-group comparison of urinary biomarkers at each time point was performed. RESULTS Thirty-six infants were included. Urinary CysC, uOPN, and uNGAL rose significantly during ibuprofen or amikacin treatment, while no difference was observed for uEGF. After adjustment for possible influencing factors, amikacin administration was associated with higher uCysC at T1 (p = 0.007) and T2 (p = 0.016), whereas ibuprofen increased uOPN (p = 0.001) and uNGAL concentration (p = 0.009) at T3. CONCLUSION Nephrotoxic therapies induce molecule-specific change patterns of renal function biomarkers in treated preterm infants. Serial assessments of these biomarkers may aid to identify neonates at risk of renal impairment and to develop tailored therapeutic approaches. IMPACT Despite the wide use of nephrotoxic therapies in neonatal settings, little is known on their effect on renal function biomarkers in preterm infants. This study describes molecule-specific change patterns of urinary biomarkers during ibuprofen and amikacin administration, suggesting underlying pathophysiological effects on renal function. Given their low analytical costs and non-invasive collection, the urinary biomarkers investigated in this study represent a promising strategy for serial monitoring of renal function in at-risk neonates and may aid the early detection of renal function impairment at different kidney levels during nephrotoxic treatments.
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Affiliation(s)
- Silvia Martini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy. .,Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy.
| | - Francesca Vitali
- Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nephrology, Dialysis and Renal Transplant Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Donadei
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nephrology, Dialysis and Renal Transplant Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Emanuel Raschi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Valeria Aiello
- Department of Experimental Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.,Nephrology, Dialysis and Renal Transplant Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Corvaglia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Fabrizio De Ponti
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Pharmacology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Silvia Galletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Neonatal Intensive Care Unit, IRCCS S. Orsola-Malpighi Hospital, Bologna, Italy
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Thänert R, Sawhney SS, Schwartz DJ, Dantas G. The resistance within: Antibiotic disruption of the gut microbiome and resistome dynamics in infancy. Cell Host Microbe 2022; 30:675-683. [PMID: 35550670 PMCID: PMC9173668 DOI: 10.1016/j.chom.2022.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/28/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Abstract
Intestinal host-microbiota interactions during the first year of life are critical for infant development. Early-life antibiotic exposures disrupt stereotypical gut microbiota maturation and adversely affect childhood health. Furthermore, antibiotics increase the abundance of resistant bacteria and enrich the resistome-the compendium of antibiotic resistance genes-within the gut microbiota. Here, we discuss acute and persistent impacts of antibiotic exposure during infancy on pediatric health, the gut microbiome, and, particularly, the resistome. Reviewing our current understanding of antibiotic resistance acquisition and dissemination within and between microbiomes, we highlight open questions, which are imperative to resolve in the face of rising bacterial resistance.
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Affiliation(s)
- Robert Thänert
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sanjam S Sawhney
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Drew J Schwartz
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
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Magers J, Prusakov P, Speaks S, Conroy S, Sánchez PJ. Safety and Efficacy of Nafcillin for Empiric Therapy of Late-Onset Sepsis in the NICU. Pediatrics 2022; 149:186703. [PMID: 35380005 DOI: 10.1542/peds.2021-052360] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE In 2014 at Nationwide Children's Hospital, the Neonatal Antimicrobial Stewardship Program recommended nafcillin over vancomycin for empirical therapy of possible late-onset sepsis (LOS) in infants without a history of methicillin-resistant Staphylococcus aureus colonization or infection. We report our experience with this guideline and assess its safety. METHODS We retrospectively reviewed all infants who received nafcillin or vancomycin for empirical treatment of possible LOS at 3 NICUs before (January 2013-May 2014) and after (January 2017-March 2019) implementation of a vancomycin reduction guideline. Safety measures included duration of blood culture positivity, recurrence of infection with the same previously identified pathogen in the 14 days after discontinuation of antibiotic therapy, and mortality. RESULTS Among 366 infants who received a first antibiotic course for possible LOS, 84% (95 of 113) and 25% (62 of 253) received empirical therapy with vancomycin before and after the guideline implementation, respectively, representing a 70% reduction. Nafcillin use increased by 368%. Duration of blood culture positivity did not differ before and after the guidance. In 2 infants, antibiotic therapy was restarted within 14 days of discontinuation of the initial therapy for recurrence of the same infection; both had received empirical vancomycin. Overall in-hospital mortality was 10%, and there was no difference before (9%) and after (10%) implementation of the vancomycin reduction guidance (odds ratio, 0.97). CONCLUSIONS Nafcillin can be a safe alternative to vancomycin for empirical therapy of LOS among NICU infants who do not have a history of methicillin-resistant S aureus infection or colonization.
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Affiliation(s)
| | | | - Sunday Speaks
- Department of Pharmacy, Riverside Methodist Hospital, Columbus, Ohio
| | - Sara Conroy
- Biostatistics Resource at Nationwide Children's Hospital(BRANCH), Nationwide Children's Hospital, Columbus, Ohio.,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Pablo J Sánchez
- Divisions of Neonatology and Pediatric Infectious Diseases, Departments of Pediatrics.,Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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Thomas R, Ondongo-Ezhet C, Motsoaledi N, Sharland M, Clements M, Velaphi S. Incidence and All-Cause Mortality Rates in Neonates Infected With Carbapenem Resistant Organisms. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.832011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IntroductionMultidrug-resistant, Gram-negative infections, particularly due to carbapenem resistant organisms (CRO), have increased globally. Few studies have reported on the burden of CRO in neonates from low-middle income countries (LMIC). This study aimed to determine the incidence and mortality rates of culture-confirmed Gram-negative infections, with a special focus on CRO in a neonatal unit from a LMIC.Materials and MethodsPositive bacterial cultures from sterile sites of infants admitted in the neonatal unit from the 1st January 2018 to 31st December 2019, were reviewed retrospectively. Type of organism, susceptibility and outcomes were recorded. Data on Gram-negative isolates, including the CRO, were extracted. Rates and outcomes were analysed.ResultsThere were 2219 neonates with organisms isolated from sterile sites (blood and cerebrospinal fluid), accounting for 30% of all admissions, giving a neonatal sepsis incidence of 17.9/1000 patient-days. There was a total of 1746 positive isolates (excluding coagulase negative Staphyloccocus). Of these, 1706 (98%) were isolated from blood, and 40 (2%) from cerebrospinal fluid. Overall, 1188 (68%) were Gram-negative, 371 (21%) Gram-positive and 187 (10.7%) fungal isolates. The common Gram-negatives were Acinetobacter baumannii (526/1188;44%) and Klebsiella pneumoniae (469/1188;40%). Carbapenem resistance was observed in 359 (68%) of the Acinetobacter baumannii (CRAB) and in 103 (18%) of the Enterobacterales (CRE) isolates, with 98% of CRE being Klebsiella pneumoniae (CR-Klebs). Twenty-four (41%) of Pseudomonas species were carbapenem resistant. Overall, carbapenem resistance was seen in 42% of all Gram-negative organisms. The rate of CRAB and CRE were 2.9 and 0.8/1000 patient-days respectively. The overall, all-cause in-hospital mortality rate in infants with Gram-negative isolates was 22%, with higher mortality rate in those infected with CRO compared to non-CRO (34% vs 13%; OR 3.44; 95% CI 2.58–4.60; p < 0.001). The mortality rate in infants with CRE was higher than those with CRAB (48% vs 33%; OR 1.85; 95% CI 1.18–2.89; p = 0.007).ConclusionWe observed a high incidence of positive cultures from sterile sites. The common organisms isolated were Gram-negatives, and among these carbapenem resistance was high and was associated with high mortality. Mortality was higher in infants with CRE compared to those with CRAB.
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Thaulow CM, Harthug S, Nilsen RM, Eriksen BH, Wathne JS, Berild D, Blix HS. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1468-1475. [PMID: 35137117 PMCID: PMC9047674 DOI: 10.1093/jac/dkac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/30/2021] [Indexed: 11/14/2022] Open
Abstract
Objectives To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life. Methods Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases. Results Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1–2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9–2.2)]. The recurrence use rate in exposed term infants (≥37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4–3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2–3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6–4.9)]. Conclusions Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity.
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Affiliation(s)
- Christian Magnus Thaulow
- Department of Clinical Science, University of Bergen, PO Box 7804, 5020, Bergen, Norway
- Department of Paediatrics and Adolescence Medicine, Haukeland University Hospital, PO Box 1400, 5021, Bergen, Norway
- Corresponding author. E-mail:
| | - Stig Harthug
- Department of Clinical Science, University of Bergen, PO Box 7804, 5020, Bergen, Norway
- Department of Research and Development, Haukeland University Hospital, PO Box 1400, 5021, Bergen, Norway
| | - Roy Miodini Nilsen
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, PO Box 7030, 5020, Bergen, Norway
| | - Beate Horsberg Eriksen
- Department of Paediatrics and Adolescence Medicine, Ålesund Hospital, PO Box 1600, 6026, Ålesund, Norway
| | - Jannicke Slettli Wathne
- Department of Quality and Development, Hospital Pharmacies Enterprises in Western Norway, PO Box 1400, 5021, Bergen, Norway
| | - Dag Berild
- Department of Clinical Medicine, University of Oslo, PO Box 1077, 0316, Oslo, Norway
| | - Hege Salvesen Blix
- Department of Pharmacy, University of Oslo, PO Box 1068 Blindern, 0316, Oslo, Norway
- Department of Drug Statistics, Norwegian Institute of Public Health, PO Box 222, 0213, Oslo, Norway
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Neonatal multidrug-resistant gram-negative infection: epidemiology, mechanisms of resistance, and management. Pediatr Res 2022; 91:380-391. [PMID: 34599280 PMCID: PMC8819496 DOI: 10.1038/s41390-021-01745-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/11/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Infants admitted to the neonatal intensive care unit, particularly those born preterm, are at high risk for infection due to the combination of an immature immune system, prolonged hospitalization, and frequent use of invasive devices. Emerging evidence suggests that multidrug-resistant gram-negative (MDR-GN) infections are increasing in neonatal settings, which directly threatens recent and ongoing advances in contemporary neonatal care. A rising prevalence of antibiotic resistance among common neonatal pathogens compounds the challenge of optimal management of suspected and confirmed neonatal infection. We review the epidemiology of MDR-GN infections in neonates in the United States and internationally, with a focus on extended-spectrum β-lactamase (ESBL)-producing Enterobacterales and carbapenem-resistant Enterobacterales (CRE). We include published single-center studies, neonatal collaborative reports, and national surveillance data. Risk factors for and mechanisms of resistance are discussed. In addition, we discuss current recommendations for empiric antibiotic therapy for suspected infections, as well as definitive treatment options for key MDR organisms. Finally, we review best practices for prevention and identify current knowledge gaps and areas for future research. IMPACT: Surveillance and prevention of MDR-GN infections is a pediatric research priority. A rising prevalence of MDR-GN neonatal infections, specifically ESBL-producing Enterobacterales and CRE, compounds the challenge of optimal management of suspected and confirmed neonatal infection. Future studies are needed to understand the impacts of MDR-GN infection on neonatal morbidity and mortality, and studies of current and novel antibiotic therapies should include a focus on the pharmacokinetics of such agents among neonates.
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Managing antibiotics wisely in a neonatal intensive care unit in a low resource setting. J Perinatol 2022; 42:965-970. [PMID: 35459905 PMCID: PMC9023725 DOI: 10.1038/s41372-022-01388-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/17/2022] [Accepted: 03/31/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Unnecessary early antibiotic exposure is deleterious, it may induce the selection of multi-drug-resistant organisms. The objective of this project was to decrease antibiotic exposure of newborns admitted to the neonatal intensive care unit at Hospital Cayetano Heredia, a level 3 unit in Lima, Peru. METHODS Quality improvement project in which we implemented an antibiotic stewardship program for early onset sepsis in the neonatal intensive care unit. Primary outcome measure was antibiotic usage rate, total number of days infants were exposed to antibacterial agents divided by 1000 patient-days. RESULTS Antibiotic usage rate declined from 291/1000 patient-days to 82/1000 patient-days during the last months of 2020, representing a total decrease of 65.1%. CONCLUSIONS Antibiotic stewardship for early-onset sepsis implemented in a perinatal center like ours is effective, appears to be safe and results in a sustained and significant decrease in the use of antibiotics for early-onset sepsis.
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Hill LF, Clements MN, Turner MA, Donà D, Lutsar I, Jacqz-Aigrain E, Heath PT, Roilides E, Rawcliffe L, Alonso-Diaz C, Baraldi E, Dotta A, Ilmoja ML, Mahaveer A, Metsvaht T, Mitsiakos G, Papaevangelou V, Sarafidis K, Walker AS, Sharland M, Clements M, Turner MA, Donà D, Lutsar I, Jacqz-Aigrain E, Heath PT, Roilides E, Rawcliffe L, Bafadal B, Alarcon Allen A, Alonso-Diaz C, Anatolitou F, Baraldi E, Del Vecchio A, Dotta A, Giuffrè M, Ilmoja ML, Karachristou K, Mahaveer A, Manzoni P, Martinelli S, Metsvaht T, Mitsiakos G, Moriarty P, Nika A, Papaevangelou V, Roehr C, Sanchez Alcobendas L, Sarafidis K, Siahanidou T, Tzialla C, Bonadies L, Booth N, Catalina Morales-Betancourt P, Cordeiro M, de Alba Romero C, de la Cruz J, De Luca M, Farina D, Franco C, Gialamprinou D, Hallik M, Ilardi L, Insinga V, Iosifidis E, Kalamees R, Kontou A, Molnar Z, Nikaina E, Petropoulou C, Reyné M, Tataropoulou K, Triantafyllidou P, Vontzalidis A, Walker AS, Sharland M. Optimised versus standard dosing of vancomycin in infants with Gram-positive sepsis (NeoVanc): a multicentre, randomised, open-label, phase 2b, non-inferiority trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:49-59. [PMID: 34843669 DOI: 10.1016/s2352-4642(21)00305-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vancomycin is the most widely used antibiotic for neonatal Gram-positive sepsis, but clinical outcome data of dosing strategies are scarce. The NeoVanc programme comprised extensive preclinical studies to inform a randomised controlled trial to assess optimised vancomycin dosing. We compared the efficacy of an optimised regimen to a standard regimen in infants with late onset sepsis that was known or suspected to be caused by Gram-positive microorganisms. METHODS NeoVanc was an open-label, multicentre, phase 2b, parallel-group, randomised, non-inferiority trial comparing the efficacy and toxicity of an optimised regimen of vancomycin to a standard regimen in infants aged 90 days or younger. Infants with at least three clinical or laboratory sepsis criteria or confirmed Gram-positive sepsis with at least one clinical or laboratory criterion were enrolled from 22 neonatal intensive care units in Greece, Italy, Estonia, Spain, and the UK. Infants were randomly assigned (1:1) to either the optimised regimen (25 mg/kg loading dose, followed by 15 mg/kg every 12 h or 8 h dependent on postmenstrual age, for 5 ± 1 days) or the standard regimen (no loading dose; 15 mg/kg every 24 h, 12 h, or 8 h dependent on postmenstrual age for 10 ± 2 days). Vancomycin was administered intravenously via 60 min infusion. Group allocation was not masked to local investigators or parents. The primary endpoint was success at the test of cure visit (10 ± 1 days after the end of actual vancomycin therapy) in the per-protocol population, where success was defined as the participant being alive at the test of cure visit, having a successful outcome at the end of actual vancomycin therapy, and not having a clinically or microbiologically significant relapse or new infection requiring antistaphylococcal antibiotics for more than 24 h within 10 days of the end of actual vancomycin therapy. The non-inferiority margin was -10%. Safety was assessed in the intention-to-treat population. This trial is registered at ClinicalTrials.gov (NCT02790996). FINDINGS Between March 3, 2017, and July 29, 2019, 242 infants were randomly assigned to the standard regimen group (n=122) or the optimised regimen group (n=120). Primary outcome data in the per-protocol population were available for 90 infants in the optimised group and 92 in the standard group. 64 (71%) of 90 infants in the optimised group and 73 (79%) of 92 in the standard group had success at test of cure visit; non-inferiority was not confirmed (adjusted risk difference -7% [95% CI -15 to 2]). Incomplete resolution of clinical or laboratory signs after 5 ± 1 days of vancomycin therapy was the main factor contributing to clinical failure in the optimised group. Abnormal hearing test results were recorded in 25 (30%) of 84 infants in the optimised group and 12 (15%) of 79 in the standard group (adjusted risk ratio 1·96 [95% CI 1·07 to 3·59], p=0·030). There were six vancomycin-related adverse events in the optimised group (one serious adverse event) and four in the standard group (two serious adverse events). 11 infants in the intention-to-treat population died (six [6%] of 102 infants in the optimised group and five [5%] of 98 in the standard group). INTERPRETATION In the largest neonatal vancomycin efficacy trial yet conducted, no clear clinical impact of a shorter duration of treatment with a loading dose was demonstrated. The use of the optimised regimen cannot be recommended because a potential hearing safety signal was identified; long-term follow-up is being done. These results emphasise the importance of robust clinical safety assessments of novel antibiotic dosing regimens in infants. FUNDING EU Seventh Framework Programme for research, technological development and demonstration.
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Affiliation(s)
- Louise F Hill
- Institute for Infection and Immunity, St George's, University of London, London, UK.
| | - Michelle N Clements
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy; Fondazione Penta, Padua, Italy
| | | | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | - Paul T Heath
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Emmanuel Roilides
- 3rd Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | | | | | - Eugenio Baraldi
- Azienda Ospedale-Universita' di Padova, Fondazione Istituto di Ricerca Pediatrica, Padova, Italy
| | | | | | | | | | | | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Michael Sharland
- Institute for Infection and Immunity, St George's, University of London, London, UK
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Goff DA, Prusakov P, Mangino JE, Sanchez PJ, Nwomeh B, Messina AP, Schellack N, Annor AS, Cassim A, Kolman S, Van Tonder L, Mawela D, Velaphi SC, Chirwa PL, Bergh D. International train the trainer neonatal antibiotic stewardship program for South African pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Debra A. Goff
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
- Division of Pharmacy Practice The Ohio State University College of Pharmacy Columbus Ohio USA
| | - Pavel Prusakov
- Department of Pharmacy Nationwide Children's Hospital Columbus Ohio USA
| | - Julie E. Mangino
- Department of Internal Medicine and Division of Infectious Diseases The Ohio State University and the Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Pablo J. Sanchez
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus Ohio USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery Nationwide Children's Hospital Columbus Ohio USA
| | | | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences University of Pretoria Pretoria South Africa
| | - Ama S. Annor
- Department of Pharmacology, Faculty of Health Sciences University of Pretoria Pretoria South Africa
- Department of Pharmacy Dr. George Mukhari Academic Hospital Ga‐Rankuwa South Africa
| | - Azraa Cassim
- Department of Pharmacy Chris Hani Baragwanath Academic Hospital Soweto South Africa
| | - Sonya Kolman
- Department of Pharmacy Nelson Mandela Children's Hospital Johannesburg South Africa
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Lindie Van Tonder
- Department of Pharmacy Netcare Femina Hospitals Ltd. Pretoria South Africa
| | - Dini Mawela
- Department of Paediatrics and Child Health Dr George Mukhari Academic Hospital Ga‐Rankuwa South Africa
| | - Sithembiso C. Velaphi
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Pinky Lea Chirwa
- Department of Neonatology Nelson Mandela Children's Hospital Johannesburg South Africa
| | - Dena Bergh
- Division of Infectious Diseases & HIV Medicine, Department of Medicine Groote Schuur Hospital University of Cape Town Cape Town South Africa
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Schlapbach LJ, van Rossum A, Carrol ED. Antibiotics for neonatal sepsis in low-income and middle-income countries-where to go from here? THE LANCET. INFECTIOUS DISEASES 2021; 21:1617-1618. [PMID: 34384534 DOI: 10.1016/s1473-3099(21)00199-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia; Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich-Eleonore Foundation, Zurich, CH-8032, Switzerland.
| | - Annemarie van Rossum
- Department of Pediatrics, Division of Infectious Diseases and Immunology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Enitan D Carrol
- Department of Clinical Infection, Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
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