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A comparison of Triple I classification with neonatal early-onset sepsis calculator recommendations in neonates born to mothers with clinical chorioamnionitis

OBJECTIVE

To compare the early-onset sepsis (EOS) calculator recommendations for infants born to mothers with clinical chorioamnionitis with those made by the Triple I classification.

STUDY DESIGN

Retrospective analysis of chorioamnionitis-exposed neonates ≥35 weeks. EOS risk was calculated with baseline risks of 0.5/1000 and 4/1000. Mothers were retrospectively categorized using the Triple I classification. Calculator recommendations were compared with the Triple I classification recommendations.

RESULTS

We included 687 chorioamnionitis-exposed neonates. With a baseline risk of 0.5/1000, the calculator recommended no evaluation in 68.4% of infants of mothers with confirmed Triple I. With a baseline risk of 4/1000, 62.3% of infants of mothers with confirmed Triple I and 57.1% of infants born to mothers who did not meet fever criteria would have received evaluation.

CONCLUSIONS

The EOS calculator with either baseline risk does not recommend evaluation in a large number of infants born to mothers with confirmed Triple I.

Association of Use of the Neonatal Early-Onset Sepsis Calculator With Reduction in Antibiotic Therapy and Safety: A Systematic Review and Meta-analysis

IMPORTANCE

The neonatal early-onset sepsis (EOS) calculator is a clinical risk stratification tool increasingly used to guide the use of empirical antibiotics for newborns. Evidence on the effectiveness and safety of the EOS calculator is essential to inform clinicians considering implementation.

OBJECTIVE

To assess the association between management of neonatal EOS guided by the neonatal EOS calculator (compared with conventional management strategies) and reduction in antibiotic therapy for newborns.

DATA SOURCES

Electronic searches in MEDLINE, Embase, Web of Science, and Google Scholar were conducted from 2011 (introduction of the EOS calculator model) through January 31, 2019.

STUDY SELECTION

All studies with original data that compared management guided by the EOS calculator with conventional management strategies for allocating antibiotic therapy to newborns suspected to have EOS were included.

DATA EXTRACTION AND SYNTHESIS

Following PRISMA-P guidelines, relevant data were extracted from full-text articles and supplements. CHARMS (Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) tools were used to assess the risk of bias and quality of evidence. Meta-analysis using a random-effects model was conducted for studies with separate cohorts for EOS calculator and conventional management strategies.

MAIN OUTCOMES AND MEASURES

The difference in percentage of newborns treated with empirical antibiotics for suspected or proven EOS between management guided by the EOS calculator and conventional management strategies. Safety-related outcomes involved missed cases of EOS, readmissions, treatment delay, morbidity, and mortality.

RESULTS

Thirteen relevant studies analyzing a total of 175 752 newborns were included. All studies found a substantially lower relative risk (range, 3%-60%) for empirical antibiotic therapy, favoring the EOS calculator. Meta-analysis revealed a relative risk of antibiotic use of 56% (95% CI, 53%-59%) in before-after studies including newborns regardless of exposure to chorioamnionitis. Evidence on safety was limited, but proportions of missed cases of EOS were comparable between management guided by the EOS calculator (5 of 18 [28%]) and conventional management strategies (8 of 28 [29%]) (pooled odds ratio, 0.96; 95% CI, 0.26-3.52; P = .95).

CONCLUSIONS AND RELEVANCE

Use of the neonatal EOS calculator is associated with a substantial reduction in the use of empirical antibiotics for suspected EOS. Available evidence regarding safety of the use of the EOS calculator is limited, but shows no indication of inferiority compared with conventional management strategies.