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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024; 404:277-293. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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2
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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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Agudelo-Pérez S, Moreno AM, Martínez-Garro J, Salazar J, Lopez R, Perdigón M, Peláez R. 16S rDNA Sequencing for Bacterial Identification in Preterm Infants with Suspected Early-Onset Neonatal Sepsis. Trop Med Infect Dis 2024; 9:152. [PMID: 39058194 PMCID: PMC11281265 DOI: 10.3390/tropicalmed9070152] [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] [Received: 05/08/2024] [Revised: 06/18/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND The high prevalence of suspected early-onset neonatal sepsis among preterm infants leads to immediate antibiotic administration upon admission. Notably, most blood cultures for suspected early-onset neonatal sepsis do not yield a causative pathogen. This study aimed to assess polymerase chain reaction (PCR) targeting the variable region V4 of the 16S ribosomal gene (16S rDNA) and Sanger sequencing for bacterial identification in preterm infants with suspected early-onset neonatal sepsis. METHODS Therefore, this prospective study was conducted. Preterm infants with suspected early-onset neonatal sepsis were included in this study. The three groups were formed based on the risk of infection and clinical sepsis. Blood samples were collected upon admission to the neonatal unit for culture and molecular analysis. PCR amplification and subsequent Sanger sequencing of the V4 region of the 16S rDNA were performed. RESULTS Twenty-eight patients were included in this study. Blood cultures were negative in 100% of the patients. Amplification and sequencing of the V4 region identified bacterial genera in 19 patients across distinct groups. The predominant taxonomically identified genus was Pseudomonas. CONCLUSIONS Amplifying the 16S rDNA variable region through PCR and subsequent Sanger sequencing in preterm neonates with suspected early-onset neonatal sepsis can enhance the identification of microbial species that cause infection, especially in negative cultures.
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Affiliation(s)
- Sergio Agudelo-Pérez
- Department of Pediatrics, Faculty of Medicine, Universidad de La Sabana, Chía 025001, Colombia;
| | - A. Melissa Moreno
- Faculty of Science and Biotechnology, Universidad CES, Medellin 050022, Colombia; (A.M.M.); (J.M.-G.)
| | - Juliana Martínez-Garro
- Faculty of Science and Biotechnology, Universidad CES, Medellin 050022, Colombia; (A.M.M.); (J.M.-G.)
| | - Jorge Salazar
- Research Center, Grupo de Estudio de Enfermedades Infecciosas y Crónicas (GEINCRO), San Martin University Foundation, Sabaneta 055450, Colombia;
| | - Ruth Lopez
- Neonatal Unit, Hospital Meissen, Bogotá 111711, Colombia;
| | - Mateo Perdigón
- Department of Pediatrics, Faculty of Medicine, Universidad de La Sabana, Chía 025001, Colombia;
| | - Ronald Peláez
- Graduate School, Universidad CES, Medellin 050022, Colombia;
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Shi W, Chen Z, Shi L, Jiang S, Zhou J, Gu X, Lei X, Xiao T, Zhu Y, Qian A, Zhou W, Lee SK, Du L, Yang J, Ma X, Hu L. Early Antibiotic Exposure and Bronchopulmonary Dysplasia in Very Preterm Infants at Low Risk of Early-Onset Sepsis. JAMA Netw Open 2024; 7:e2418831. [PMID: 38935376 PMCID: PMC11211957 DOI: 10.1001/jamanetworkopen.2024.18831] [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: 02/03/2024] [Accepted: 04/24/2024] [Indexed: 06/28/2024] Open
Abstract
Importance The overutilization of antibiotics in very preterm infants (VPIs) at low risk of early-onset sepsis (EOS) is associated with increased mortality and morbidities. Nevertheless, the association of early antibiotic exposure with bronchopulmonary dysplasia (BPD) remains equivocal. Objective To evaluate the association of varying durations and types of early antibiotic exposure with the incidence of BPD in VPIs at low risk of EOS. Design, Setting, and Participants This national multicenter cohort study utilized data from the Chinese Neonatal Network (CHNN) which prospectively collected data from January 1, 2019, to December 31, 2021. VPIs less than 32 weeks' gestational age or with birth weight less than 1500 g at low risk of EOS, defined as those born via cesarean delivery, without labor or rupture of membranes, and no clinical evidence of chorioamnionitis, were included. Data analysis was conducted from October 2022 to December 2023. Exposure Early antibiotic exposure was defined as the total number of calendar days antibiotics were administered within the first week of life, which were further categorized as no exposure, 1 to 4 days of exposure, and 5 to 7 days of exposure. Main Outcomes and Measures The primary outcome was the composite of moderate to severe BPD or mortality at 36 weeks' post menstrual age (PMA). Logistic regression was employed to assess factors associated with BPD or mortality using 2 different models. Results Of the 27 176 VPIs included in the CHNN during the study period (14 874 male [54.7%] and 12 302 female [45.3%]), 6510 (23.9%; 3373 male [51.8%] and 3137 female [48.2.%]) were categorized as low risk for EOS. Among them, 1324 (20.3%) had no antibiotic exposure, 1134 (17.4%) received 1 to 4 days of antibiotics treatment, and 4052 (62.2%) received 5 to 7 days of antibiotics treatment. Of the 5186 VPIs who received antibiotics, 4098 (79.0%) received broad-spectrum antibiotics, 888 (17.1%) received narrow-spectrum antibiotics, and 200 (3.9%) received antifungals or other antibiotics. Prolonged exposure (5-7 days) was associated with increased likelihood of moderate to severe BPD or death (adjusted odds ratio [aOR], 1.23; 95% CI, 1.01-1.50). The use of broad-spectrum antibiotics (1-7 days) was also associated with a higher risk of moderate to severe BPD or death (aOR, 1.27; 95% CI, 1.04-1.55). Conclusions and Relevance In this cohort study of VPIs at low risk for EOS, exposure to prolonged or broad-spectrum antibiotics was associated with increased risk of developing moderate to severe BPD or mortality. These findings suggest that VPIs exposed to prolonged or broad-spectrum antibiotics early in life should be monitored for adverse outcomes.
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Affiliation(s)
- Wei Shi
- Neonatal Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Zheng Chen
- Neonatal Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Liping Shi
- Neonatal Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Siyuan Jiang
- Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
| | - Jianguo Zhou
- Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
| | - Xinyue Gu
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Tiantian Xiao
- Department of Neonatology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yanping Zhu
- Department of Neonatology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Aimin Qian
- Department of Neonatology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Wenhao Zhou
- Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
| | - Shoo K. Lee
- Maternal-Infant Care Research Center and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Lizhong Du
- Neonatal Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Jie Yang
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiaolu Ma
- Neonatal Intensive Care Unit, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Liyuan Hu
- Department of Neonatology, Children’s Hospital of Fudan University, Shanghai, China
- National Health Commission Key Laboratory of Neonatal Diseases, Fudan University, Children’s Hospital of Fudan University, Shanghai, China
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5
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Qian W, Han C, Xie S, Xu S. Prediction model of death risk in patients with sepsis and screening of biomarkers for prognosis of patients with myocardial injury. Heliyon 2024; 10:e27209. [PMID: 38449610 PMCID: PMC10915407 DOI: 10.1016/j.heliyon.2024.e27209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024] Open
Abstract
This study aimed to create a robust prediction model for sepsis patient mortality and identify key biomarkers in those with myocardial injury. A retrospective analysis of 261 sepsis inpatients was conducted, with 44 deaths and 217 recoveries. Key factors were assessed via univariate and multivariate analyses, revealing myocardial injury, shock, and pulmonary infection as independent mortality risk factors. Using LASSO regression, a reliable prediction model was developed and internally validated. Additionally, procalcitonin (PCT) emerged as a sensitive biomarker for myocardial injury prediction in sepsis patients. In summary, this study highlights myocardial injury, shock, and pulmonary infection as independent risk factors for sepsis-related deaths. The LASSO-based prediction model effectively forecasts the prognosis of septic patients with myocardial injury, with PCT showing promise as a predictive biomarker.
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Affiliation(s)
- Weiwei Qian
- Laboratory of Emergency Medicine, West China Hospital, and Disaster Medical Center, Sichuan University, Chengdou, 610041, PR China
- Shangjinnanfu Hospital, West China Hospital, Sichuan University, PR China
| | - Cunqiao Han
- Laboratory of Emergency Medicine, West China Hospital, and Disaster Medical Center, Sichuan University, Chengdou, 610041, PR China
- Shangjinnanfu Hospital, West China Hospital, Sichuan University, PR China
| | - Shenglong Xie
- Department of Thoracic Surgery, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdou, 610041, PR China
| | - Shuyun Xu
- Laboratory of Emergency Medicine, West China Hospital, and Disaster Medical Center, Sichuan University, Chengdou, 610041, PR China
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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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7
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Coggins SA, Willis Z, Benjamin DK, Mukhopadhyay S, Laughon M, Greenberg RG, Clark RH, Puopolo KM. Early antibiotic exposure in very-low birth weight infants and infection risk at 3-7 days after birth. J Perinatol 2023; 43:1158-1165. [PMID: 37491474 PMCID: PMC10529484 DOI: 10.1038/s41372-023-01737-x] [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: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To determine rates of late-onset infection (LOI) during postnatal days 3-7 among preterm infants, based on antibiotic exposure during days 0-2. STUDY DESIGN Retrospective cohort study of infants born <1500 grams and ≤30 weeks gestation, 2005-2018. We analyzed the incidence and microbiology of LOI at days 3-7 based on antibiotic exposure during postnatal days 0-2. RESULTS The cohort included 88,574 infants, of whom 85% were antibiotic-exposed. Fewer antibiotic-exposed compared to unexposed infants developed LOI (1.5% vs. 2.1%; adjusted hazard ratio, 0.28, 95% CI 0.24-0.33). Among antibiotic-exposed compared to unexposed infants, Gram-negative (38% vs. 28%, p = 0.002) and fungal (11% vs. 1%, p < 0.001) species were more commonly isolated, and gram-positive organisms (49% vs. 70%, p < 0.001) were less commonly isolated. CONCLUSIONS We observed low overall rates of LOI at days 3-7 after birth, but antibiotic exposure from birth was associated with lower rates, and with differing microbiology, compared to no exposure.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Zachary Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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8
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Coggins SA, Mukhopadhyay S, Triebwasser J, Downes KJ, Christie JD, Puopolo KM. Association of delivery risk phenotype with early-onset sepsis in preterm infants. J Perinatol 2023; 43:1166-1172. [PMID: 37543652 PMCID: PMC10530160 DOI: 10.1038/s41372-023-01743-z] [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: 05/25/2023] [Revised: 07/18/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE To determine delivery risk phenotype-specific incidence of early-onset sepsis (EOS) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born <35 weeks' gestation at four perinatal centers during 2017-2021. Infants were classified into one of six delivery risk phenotypes incorporating delivery mode, presence of labor, and duration of rupture of membranes (ROM). The primary outcome was EOS incidence within the overall cohort and each risk phenotype. RESULTS Among 2937 preterm infants, 21 had EOS (0.7%, or 7.1 cases/1000 preterm infants). The majority of EOS cases (13/21, 62%) occurred in the setting of prolonged ROM ≥ 18 h, with a phenotype incidence of 23.8 cases/1000 preterm infants. There were no EOS cases among infants born by cesarean section without ROM (with or without labor), nor via cesarean section with ROM < 18 h without labor. CONCLUSION Delivery risk phenotyping may inform EOS risk stratification in preterm infants.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jourdan Triebwasser
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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9
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Chu M, Lin J, Wang M, Liao Z, Cao C, Hu M, Ding Y, Liu Y, Yue S. Restrictive Use of Empirical Antibiotics Is Associated with Improved Short Term Outcomes in Very Low Birth Weight Infants: A Single Center, Retrospective Cohort Study from China. Antibiotics (Basel) 2023; 12:741. [PMID: 37107103 PMCID: PMC10135071 DOI: 10.3390/antibiotics12040741] [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] [Received: 02/18/2023] [Revised: 03/14/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Antibiotics are essential for treating neonatal sepsis, but abuse or inappropriate use of antibiotics have harmful adverse effects. The inappropriate use of antibiotics has led to the significant increase in bacterial antimicrobial resistance in the neonatal intensive care unit (NICU). The aim of this study was to retrospectively analyze the changes in antibiotic usages in a NICU after the implementation of an antibiotic stewardship program and to determine the impact of this implementation on the short-term clinical outcomes of very low birth weight (VLBW) infants. The antibiotic stewardship program was initiated in the NICU in early 2015. For analysis, all eligible VLBW infants born from 1 January 2014 to 31 December 2016 were enrolled, and we classified the year 2014 as pre-stewardship, 2015 as during stewardship, and 2016 as post-stewardship. A total of 249 VLBW infants, including 96 cases in the 2014 group, 77 cases in the 2015 group, and 76 cases in the 2016 group, were included for final analysis. Empirical antibiotics were used in over 90% of VLBW infants in all three groups during their NICU stay. Over the 3-year period, the duration of an initial antibiotic course was significantly reduced. The proportion of patients receiving an initial antibiotic course for ≤3 days gradually increased (2.1% vs. 9.1% vs. 38.2%, p < 0.001), while the proportion of babies treated with an initial antibiotic course >7 days significantly decreased (95.8% vs. 79.2% vs. 39.5%, p < 0.001). The total days of antibiotic usage during the entire NICU stay also showed a significant reduction (27.0 vs. 21.0 vs. 10.0, p < 0.001). After adjusting for confounders, the reduction in antibiotic usage was associated with decreased odds of having an adverse composite short-term outcome (aOR = 5.148, 95% CI: 1.598 to 16.583, p = 0.006). To assess the continuity of antibiotic stewardship in the NICU, data from 2021 were also analyzed and compared to 2016. The median duration of an initial antibiotic course further decreased from 5.0 days in 2016 to 4.0 days in 2021 (p < 0.001). The proportion of an initial antibiotic course in which antibiotics were used for ≤3 days increased (38.2% vs. 56.7%, p = 0.022). Total antibiotic usage days during the entire NICU stay also decreased from 10.0 days in 2016 to 7.0 days in 2021 (p = 0.010). The finding of this study strongly suggests that restricting antibiotic use in VLBW infants is beneficial and can be achieved safely and effectively in China.
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Affiliation(s)
- Meiyan Chu
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Jing Lin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Mingjie Wang
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Zhengchang Liao
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Chuanding Cao
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Ming Hu
- Xiangya School of Public Health, Central South University, Changsha 410078, China
| | - Ying Ding
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Yang Liu
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Shaojie Yue
- Department of Neonatology, Xiangya Hospital of Central South University, Changsha 410008, China
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Vatne A, Hapnes N, Stensvold HJ, Dalen I, Guthe HJ, Støen R, Brigtsen AK, Rønnestad AE, Klingenberg C. Early Empirical Antibiotics and Adverse Clinical Outcomes in Infants Born Very Preterm: A Population-Based Cohort. J Pediatr 2023; 253:107-114.e5. [PMID: 36179887 DOI: 10.1016/j.jpeds.2022.09.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the association between empirical antibiotic therapy in the first postnatal week in uninfected infants born very preterm and the risk of adverse outcomes until discharge. STUDY DESIGN Population-based, nationwide registry study in Norway including all live-born infants with a gestational age <32 weeks surviving first postnatal week without sepsis, intestinal perforation, or necrotizing enterocolitis (NEC) between 2009 and 2018. Primary outcomes were severe NEC, death after the first postnatal week, and/or a composite outcome of severe morbidity (severe NEC, severe bronchopulmonary dysplasia [BPD], severe retinopathy of prematurity, late-onset sepsis, or cystic periventricular leukomalacia). The association between empirical antibiotics and adverse outcomes was assessed using multivariable logistic regression models, adjusting for known confounders. RESULTS Of 5296 live-born infants born very preterm, 4932 (93%) were included. Antibiotics were started in first postnatal week in 3790 of 4932 (77%) infants and were associated with higher aOR of death (aOR 9.33; 95% CI: 1.10-79.5, P = .041), severe morbidity (aOR 1.88; 95% CI: 1.16-3.05, P = .01), and severe BPD (aOR 2.17; 95% CI: 1.18-3.98; P = .012), compared with those not exposed. Antibiotics ≥ 5 days were associated with higher odds of severe NEC (aOR 2.27; 95% CI: 1.02-5.06; P = .045). Each additional day of antibiotics was associated with 14% higher aOR of death or severe morbidity and severe BPD. CONCLUSIONS Early and prolonged antibiotic exposure within the first postnatal week was associated with severe NEC, severe BPD, and death after the first postnatal week.
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Affiliation(s)
- Anlaug Vatne
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nina Hapnes
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Ingvild Dalen
- Department of Research, Section of Biostatistics, Stavanger University Hospital, Stavanger, Norway
| | - Hans Jørgen Guthe
- Department of Paediatrics and Adolescents Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ragnhild Støen
- Paediatric Department, St. Olav's University Hospital, Trondheim, Norway
| | - Anne Karin Brigtsen
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Arild E Rønnestad
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Medical faculty, Institute for clinical medicine, University of Oslo, Oslo, Norway
| | - 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.
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11
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Shen R, Embleton N, Lyng Forman J, Gale C, Griesen G, Sangild PT, Uthaya S, Berrington J. Early antibiotic use and incidence of necrotising enterocolitis in very preterm infants: a protocol for a UK based observational study using routinely recorded data. BMJ Open 2022; 12:e065934. [PMID: 36379645 PMCID: PMC9667987 DOI: 10.1136/bmjopen-2022-065934] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/22/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Necrotising enterocolitis (NEC) remains a major contributor to preterm mortality and morbidity. Prolonged duration of antibiotic therapy after delivery is associated with later NEC development but recent evidence suggests that absence of antibiotic treatment after delivery may also increase NEC risk. We will explore this controversy using a large pre-existing dataset of preterm infants in the UK. METHODS AND ANALYSIS This is a retrospective cohort study using data from UK National Neonatal Research Database (NNRD) for infants born 1 January 2012 to 31 December 2020. Eligible infants will be <32 weeks gestation, alive on day 3. Primary outcome is development of severe NEC, compared in infants receiving early antibiotics (days 1-2 after birth) and those not. Subgroup analysis on duration of early antibiotic exposure will also occur. Secondary outcomes are: late onset sepsis, total antibiotic use, predischarge mortality, retinopathy of prematurity, intraventricular haemorrhage, bronchopulmonary dysplasia, focal intestinal perforation and any abdominal surgery. To address competing risks, incidence of death before day 7, 14 and 28 will be analysed. We will perform logistic regression and propensity score matched analyses. Statistical analyses will be guided by NEC risk factors, exposures and outcome presented in a causal diagram. These covariates include but are not limited to gestational age, birth weight, small for gestational age, sex, ethnicity, delivery mode, delivery without labour, Apgar score, early feeding and probiotic use. Sensitivity analyses of alternate NEC definitions, specific antibiotics and time of initiation will occur. ETHICS AND DISSEMINATION We will use deidentified data from NNRD, which holds permissions for the original data, from which parents can opt out and seek study-specific research ethics approval. The results will help to determine optimal use of early antibiotics for very preterm infants. IMPLICATIONS This data will help optimise early antibiotic use in preterm infants. TRIAL REGISTRATION NUMBER ISRCTN55101779.
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Affiliation(s)
- Rene Shen
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhgaen, Denmark
| | - Nicholas Embleton
- Neonatology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Population Health Sciences, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | | | - Chris Gale
- Neonatal Medicine, School of Public Health, Imperial College London, London, UK
| | - Gorm Griesen
- Neonatology, Odense University Hospital, Odense, Denmark
| | - Per Torp Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, Copenhgaen, Denmark
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
| | - Sabita Uthaya
- Faculty of Medicine, Imperial College London, London, UK
| | - Janet Berrington
- Neonatology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Clinical and Translational Research Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
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12
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Manzar S. Association between the early use of antibiotics in infants born preterm and severe cerebral lesions and moderate-to-severe bronchopulmonary dysplasia. J Pediatr 2022; 248:133. [PMID: 35700793 DOI: 10.1016/j.jpeds.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Shabih Manzar
- Section of Neonatology, Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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Reyes-García DV, Canul-Euan AA, Rivera-Rueda MA, Cruz-Alvarado CE, Bermejo-Martínez LB, Arreola-Ramírez G, Cordero-González G, Carrera-Muiños S, Diaz-Valencia JD, Estrada-Gutiérrez G, Irles C, Gonzalez-Perez G. Neonatal Antibiotic Treatment Can Affect Stool Pattern and Oral Tolerance in Preterm Infants. Life (Basel) 2022; 12:life12071043. [PMID: 35888130 PMCID: PMC9319374 DOI: 10.3390/life12071043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Preterm neonates are at high risk of infectious and inflammatory diseases which require antibiotic treatment. Antibiotics influence neonatal gut microbiome development, and intestinal dysbiosis has been associated with delayed gastrointestinal transit. Neonates who take less time to pass meconium have a better tolerance to enteral feeding. We analyzed the effect of neonatal antibiotic treatment on the stool pattern and oral tolerance in 106 preterm infants < 33 weeks gestational age. Neonates were classified in 3 groups according to neonatal antibiotic (ABT) treatment days: no antibiotics, 3−7 d ABT, and ≥8 d ABT. Preterm infants from the ≥8 d ABT group took longer to pass meconium and to start green and yellow stools, took longer to reach 100 and 150 mL/kg/day, and reached reduced volumes in enteral feeds at day of life 14 and 28 than infants from no ABT and 3−7 d ABT groups. Multiple linear regression models showed that neonatal antibiotic treatment, birth weight, invasive mechanical ventilation, surfactant, enteral feeding start day, neonatal parenteral nutrition, and neonatal fasting days are associated with the stool pattern and oral tolerance in preterm infants.
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Affiliation(s)
- Diana Verónica Reyes-García
- Neonatal Intensive Care Unit, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (D.V.R.-G.); (M.A.R.-R.); (C.E.C.-A.); (G.C.-G.); (S.C.-M.)
| | - Arturo Alejandro Canul-Euan
- Department of Developmental Neurobiology, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico;
| | - María Antonieta Rivera-Rueda
- Neonatal Intensive Care Unit, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (D.V.R.-G.); (M.A.R.-R.); (C.E.C.-A.); (G.C.-G.); (S.C.-M.)
| | - Claudia Edith Cruz-Alvarado
- Neonatal Intensive Care Unit, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (D.V.R.-G.); (M.A.R.-R.); (C.E.C.-A.); (G.C.-G.); (S.C.-M.)
| | - Luisa Bertha Bermejo-Martínez
- Department of Immunobiochemistry, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico;
| | - Gabriela Arreola-Ramírez
- Department of Pediatric Follow-Up, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico;
| | - Guadalupe Cordero-González
- Neonatal Intensive Care Unit, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (D.V.R.-G.); (M.A.R.-R.); (C.E.C.-A.); (G.C.-G.); (S.C.-M.)
| | - Sandra Carrera-Muiños
- Neonatal Intensive Care Unit, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (D.V.R.-G.); (M.A.R.-R.); (C.E.C.-A.); (G.C.-G.); (S.C.-M.)
| | - Juan Daniel Diaz-Valencia
- Department of Physiology and Cellular Development, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (J.D.D.-V.); (C.I.)
| | - Guadalupe Estrada-Gutiérrez
- Research Direction, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico;
| | - Claudine Irles
- Department of Physiology and Cellular Development, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (J.D.D.-V.); (C.I.)
| | - Gabriela Gonzalez-Perez
- Department of Physiology and Cellular Development, National Institute of Perinatology “Isidro Espinosa de los Reyes”, Mexico City 11000, Mexico; (J.D.D.-V.); (C.I.)
- Correspondence: ; Tel.: +52-55-55209900 (ext. 340)
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Association between duration of early empiric antibiotics and necrotizing enterocolitis and late-onset sepsis in preterm infants: a multicenter cohort study. Eur J Pediatr 2022; 181:3715-3724. [PMID: 35927379 PMCID: PMC9508214 DOI: 10.1007/s00431-022-04579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/14/2022] [Accepted: 07/23/2022] [Indexed: 11/23/2022]
Abstract
UNLABELLED The threshold to initiate empiric antibiotics for suspicion of early-onset sepsis (EOS) is low in preterm infants. Antibiotics' effects on short-term outcomes have recently been debated. We aimed at exploring the extent of early empiric antibiotic exposure (EEAE) in preterm infants and the association between the duration of EEAE with necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) within different EEAE groups. EEAE practice for suspicion of EOS was evaluated in all included infants (gestational age < 30 weeks) born in 9 centers in the Netherlands and Belgium between Oct. 2014 and Jan. 2019. EEAE association with NEC and LOS development was analyzed by multivariate regression. After excluding 56 EOS cases, 1259 infants were included. A total of 1122 infants (89.1%) were exposed to empirical antibiotics for the suspicion of EOS of whom 802 (63.7%) had short (≤ 72 h) and 320 (25.4%) prolonged EEAE (> 72 h). Infants with EEAE ≤ 72 h had a lower incidence of NEC compared to both infants without EEAE (adjusted odds ratio (aOR) 0.39; 95% confidence interval (CI) [0.19-0.80]; p = 0.01) and with prolonged EEAE (> 72 h) (aOR [95%CI]: 0.58 [0.35-0.96]; p = 0.03). With every additional day of EEAE, LOS incidence decreased (aOR [95%CI]: 0.90 [0.85-0.97]; p = 0.003). CONCLUSION Almost 90% of preterm infants who have negative blood culture results in the first 72 h of life are exposed to EEAE under suspicion of EOS. One-fourth has prolonged EEAE. Duration of EEAE was differently associated with NEC and LOS incidence. The effects of antibiotics, and potentially induced microbial dysbiosis related to development of NEC and LOS, should further be explored. WHAT IS KNOWN • Preterm infants often receive antibiotics empirically directly after birth for suspicion of early-onset sepsis. • The effects of the duration of early empirical antibiotic exposure on the risk for necrotizing enterocolitis and late-onset sepsis are debated. WHAT IS NEW • Almost 90% of preterm infants with a gestational age below 30 weeks are exposed to antibiotics empirically after birth despite negative culture results. In a quarter of these culture-negative infants, empirical antibiotics are prolonged. • A short course of empirical antibiotics (≤72h) is associated with decreased odds for necrotizing enterocolitis compared to both prolonged (>72h) or no empirical antibiotics after birth. Furthermore, every additional day of empirical antibiotic exposure is associated with decreased risk for late-onset sepsis in the first month of life.
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