Antibiotic stewardship in perinatal and neonatal care

Antimicrobial Stewardship: A Correct Management to Reduce Sepsis in NICU Settings

The discovery of antimicrobial drugs has led to a significant increase in survival from infections; however, they are very often prescribed and administered, even when their use is not necessary and appropriate. Newborns are particularly exposed to infections due to the poor effectiveness and the immaturity of their immune systems. For this reason, in Neonatal Intensive Care Units (NICUs), the use of antimicrobial drugs is often decisive and life-saving, and it must be started promptly to ensure its effectiveness in consideration of the possible rapid evolution of the infection towards sepsis. Nevertheless, the misuse of antibiotics in the neonatal period leads not only to an increase in the development and wide spreading of antimicrobial resistance (AMR) but it is also associated with various short-term (e.g., alterations of the microbiota) and long-term (e.g., increased risk of allergic disease and obesity) effects. It appears fundamental to use antibiotics only when strictly necessary; specific decision-making algorithms and electronic calculators can help limit the use of unnecessary antibiotic drugs. The aim of this narrative review is to summarize the right balance between the risks and benefits of antimicrobial therapy in NICUs; for this purpose, specific Antimicrobial Stewardship Programs (ASPs) in neonatal care and the creation of a specific antimicrobial stewardship team are requested.

Nosocomial Infections in the Neonatal Intensive Care Unit

Nosocomial infections are relatively common in the NICU. These infections increase morbidity and mortality, particularly in the smallest and most fragile infants. The impact of these infections on long-term outcomes and health-care costs is devastating. Worldwide efforts to decrease the incidence of nosocomial infections have focused on implementing specific prevention protocols such as handwashing, central line teams, care bundles, and antimicrobial stewardship. This review summarizes common nosocomial infections in patients in the NICU.

Next-generation sequencing-based detection of Ureaplasma in the gastric fluid of neonates with respiratory distress and chorioamnionitis

BACKGROUND

Respiratory distress is common in neonates admitted to neonatal intensive care units. Additionally, infectious diseases such as intrauterine infections or vertical transmission are important underlying causes of respiratory failure. However, pathogens often cannot be identified in neonates, and there are many cases in which antibacterial drugs are empirically administered. Next-generation sequencing (NGS) is advantageous in that it can detect trace amounts of bacteria that cannot be detected by culturing or bacteria that are difficult to cultivate. However, there are few reports on the diagnosis of infectious diseases using NGS in the neonatal field, especially those targeting respiratory distress.

OBJECTIVE

The purpose of our study was to investigate the microorganisms associated with neonatal respiratory distress and to determine whether less invasive collection specimens such as plasma and gastric fluid are useful.

METHODS

Neonates were prospectively recruited between January and August 2020 from Nagoya University Hospital. The inclusion criteria were as follows: 1) admission to the neonatal intensive care unit; 2) respiratory distress presentation within 48 h of birth; and 3) suspected infection, collection of blood culture, and administration of antibiotics. Plasma samples and blood cultures were simultaneously collected. Gastric fluid samples were also collected if the patient was not started on enteral nutrition. Information on the patients and their mothers were collected from the medical records. DNA was extracted from 140 µL of plasma and gastric fluid samples. DNA sequencing libraries were prepared, and their quality was analyzed. DNA libraries were sequenced using high-throughput NGS. The NGS data of plasma and gastric fluid samples were analyzed using the metagenomic pipeline PATHDET, which calculated the number of reads assigned to microorganisms and their relative abundance. Putative pathogens were listed.

RESULTS

Overall, 30 plasma samples and 25 gastric fluid samples from 30 neonates were analyzed. Microorganism-derived reads of gastric fluid samples were significantly higher than those of plasma samples. Transient tachypnea of the newborn was the most common cause of respiratory distress with 13 cases (43%), followed by respiratory distress syndrome with 7 cases (23%). There were 8 cases (29%) of chorioamnionitis and 7 cases (25%) of funisitis pathologically diagnosed. All blood cultures were negative, and only two gastric fluid cultures were positive for group B Streptococcus (Patient 15) and Candida albicans (Patient 24). Putative pathogens that met the positive criteria for PATHET were detected in four gastric fluid samples, one of which was group B Streptococcus from Patient 15. In the gastric fluid sample of Patient 24, Candida albicans were detected by NGS but did not meet the positive criteria for PATHDET. Cluster analysis of the plasma samples divided them into two study groups, and the indicator genera of each cluster (Phormidium or Toxoplasma) are shown in Figure 1. Clinical findings did not show any significant differences between the two groups. Cluster analysis of the gastric fluid samples divided them into three study groups, and the indicator genera of each cluster (Ureaplasma, Nostoc, and Streptococcus) are shown in Figure 2. The incidence rate of chorioamnionitis was significantly higher in Ureaplasma group than in the other two groups.

CONCLUSION

Gastric fluid may be useful for assessing neonatal patients with respiratory distress. To the best of our knowledge, this was the first study to reveal that the presence of Ureaplasma in the gastric fluid of neonates with respiratory distress was associated with chorioamnionitis. The early diagnosis of intra-amniotic infections using gastric fluid and its treatment may change the treatment strategy for neonatal respiratory distress. Screening for Ureaplasma in neonates with respiratory distress may reduce the need for empirical antibiotic administration. Further research is required to confirm these findings.

Epidemiologic Changes of Neonatal Early-onset Sepsis After the Implementation of Universal Maternal Screening for Group B Streptococcus in Hong Kong

BACKGROUND

The epidemiology of neonatal early-onset sepsis (EOS) has changed with time and with changes in prevention strategy. Population-representative contemporary data provide insights on how to further improve EOS prevention and triage strategies.

METHODS

Neonates born in public hospitals in Hong Kong from January 1, 2006, to December 31, 2017 were included. The epidemiological characteristics of EOS and the use of intrapartum antibiotic prophylaxis (IAP) were compared between the 2 epochs before (January 1, 2006 to December 31, 2011) and after (January 1, 2012 to December 31, 2017) the territory-wide implementation of universal maternal group B Streptococcus (GBS) screening.

RESULTS

EOS developed in 1.07‰ of live births (522/490,034). After the implementation of universal GBS screening, the EOS rate decreased in neonates born ≥34 weeks (1.17‰-0.56‰, P < 0.001) and remained similar in those born <34 weeks (7.8‰-10.9‰, P = 0.15), whereas the proportions of IAP coverage increased in both groups [7.6%-23.3% ( P < 0.001) and 28.5%-52.0% ( P < 0.001), respectively]. The major pathogen for EOS shifted from GBS to Escherichia coli , and for early-onset meningitis from GBS to Streptococcus bovis . IAP was associated with subsequent isolation of pathogens resistant to ampicillin [adjusted odds ratio (aOR) 2.3; 95% confidence interval (CI): 1.3-4.2], and second-generation [aOR 2.0; 95% CI: 1.02-4.3] and third-generation [aOR 2.2; 95% CI: 1.1-5.0] cephalosporins.

CONCLUSIONS

Pathogen profile of EOS changed with the implementation of universal GBS screening. S. bovis has emerged as a more common pathogen associated with the risk of meningitis. IAP may not be as effective in reducing EOS rate among infants born <34 weeks as compared with those ≥34 weeks, and newer strategies may be needed.

Azithromycin exposure during pregnancy disturbs the fetal development and its characteristic of multi-organ toxicity

AIMS

Azithromycin is widely used in clinical practice for treating maternal infections during pregnancy. Meanwhile, azithromycin, as an "emerging pollutant", is increasingly polluting the environment due to the rapidly increasing usage (especially after the COVID-19). Previous studies have suggested a possible teratogenic risk of prenatal azithromycin exposure (PAzE), but its effects on fetal multi-organ development are still unclear. This study aimed to explore the potential impacts of PAzE.

MATERIALS AND METHODS

We focused on pregnancy outcomes, maternal/fetal serum phenotypes, and fetal multiple organ development in mice at different doses (50/200 mg/kg·d) during late pregnancy or at 200 mg/kg·d during different stages (mid-/late-pregnancy) and courses (single-/multi-course).

KEY FINDINGS

The results showed PAzE increased the rate of the absorbed fetus during mid-pregnancy and increased the intrauterine growth retardation rate (IUGR) during late pregnancy. PAzE caused multiple blood phenotypic changes in maternal and fetal mice, among which the number and degree of changes in fetal blood indicators were more significant. Moreover, PAzE inhibited long bone/cartilage development and adrenal steroid synthesis, promoting hepatic lipid production and ovarian steroid synthesis in varying degrees. The order of severity might be bone/cartilage > liver > gonads > other organs. PAzE-induced multi-organ alterations differed in stages, courses doses and fetal sex. The most apparent changes might be in high-dose, mid-pregnancy, multi-course, and female, while there was no typical rule for a dose-response relationship.

SIGNIFICANCE

This study confirmed PAzE could cause fetal developmental abnormalities and multi-organ functional alterations, which deepens the comprehensive understanding of azithromycin's fetal developmental toxicity.

Evaluating the Impact of the 2017 Dutch Neonatal Early-Onset Sepsis Guideline

BACKGROUND

In 2017, a new Dutch neonatal early-onset sepsis (EOS) guideline was implemented. It is an adaptation from the United Kingdom National Institute for Health and Care Excellence guideline and focuses on maternal and neonatal risk factors. We aim to assess if this guideline performs better at reducing the rate of antibiotic treatment for EOS than the old Dutch categorical EOS guideline, which focused primarily on group B streptococcus (GBS) testing and prophylaxis.

METHODS

We performed a single-center retrospective cohort study in the Netherlands. Data were collected from two 12-month epochs (2015 vs. 2019). Neonates were included when treated for suspected EOS or when observed for an elevated EOS risk.

RESULTS

The empirical antibiotic rate was 4.6% in both years. Prolonged antibiotic treatment (>48 u) increased from 24% in 2015 to 39% in 2019 ( P = 0.021). Adherence to the guideline decreased from 98% in 2015 to 84% in 2019 ( P < 0.001). Strict adherence in 2019 would have led to more antibiotic treatment (5.1% instead of 4.6%). The EOS incidence rate was comparable, namely 0.6% in 2015 and 0.0% in 2019 ( P = 0.480). The change in the definition of risk factors in 2019 led to less antibiotic treatment in case of a maternal fever during birth, from 48% in 2015 to 26% in 2019 ( P < 0.001).

CONCLUSIONS

The new Dutch categorical EOS guideline does not achieve its intended purpose of reducing empiric antibiotic therapy for suspected EOS. We advocate the need for a new screening strategy.

Establishing obstetrics-specific metrics and interventions for antimicrobial stewardship

Background

To describe baseline antimicrobial stewardship (AMS) metrics and apply AMS interventions in an inpatient obstetrical population.

Methods

From October 2018 to October 2019, our tertiary-care obstetrical center reviewed components of our AMS program, which included: (1) antimicrobial consumption data, (2) point prevalence surveys (PPS), and (3) prospective audit and feedback. We reviewed institutional data for antimicrobial consumption from the pharmacy database. Detailed point prevalence surveys were conducted for all antimicrobial prescriptions on two predefined dates each month. Daily audits and feedback assessed the appropriateness of all non-protocolized antimicrobials.

Results

Our average antimicrobial length of therapy (LOT) was 12 days per 100 patient-days, where erythromycin (2.33), amoxicillin (2.28), and ampicillin (1.81) were the greatest contributors. Point prevalence surveys revealed that 28.8% of obstetrical inpatients were on antimicrobials, of which 11.2% were inappropriate. Protocolized antimicrobials were 62% less likely (p = 0.027) to be inappropriate. From 565 audited prescriptions, 110 (19.5%) resulted in feedback, where 90% of recommendations were accepted and implemented. The most common reasons for interventions include incorrect dosage, recommending a diagnostic test before continuing antimicrobials, and changing antimicrobials based on specific culture and sensitivity.

Conclusions

Antimicrobial use in obstetrics is unique compared to general inpatients. We provide a baseline set of metrics for AMS at our obstetrical center intending to lay the groundwork for AMS programming in our discipline. Antimicrobial protocolization, as well as audit and feedback, are feasible interventions to improve antimicrobial prescribing patterns.

Canine Cesarean Section: Emergency and Elective

Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting proper ovulation timing to accurately predict the due date will allow a planned, elective CS as an excellent alternative to a high-risk natural whelping, and possible dystocia, for certain breeds and situations. Techniques for ovulation timing, anesthesia, and surgery tips are provided.

Utilizing ultrasound in suspected necrotizing enterocolitis with equivocal radiographic findings

BACKGROUND

To examine the use of abdominal ultrasound (AUS) as a diagnostic adjunct in the diagnosis of necrotizing enterocolitis (NEC) in cases where abdominal radiography (AXR) is equivocal in order to reduce unnecessary antibiotic use in neonates.

METHODS

Retrospective study (2017-2019) of infants undergoing NEC evaluation with equivocal AXR findings (n = 54). Paired AXR and AUS were reviewed with respect to presence or absence of pneumatosis. Concordance of AUS findings with decision to treat for NEC was evaluated.

RESULTS

Among 54 infants where AXR was equivocal, AUS demonstrated presence of pneumatosis in 22 patients (41%), absence of pneumatosis in 31 patients (57%), and was equivocal in 1 patient. All patients with pneumatosis on AUS were treated for NEC. Of 31 patients without pneumatosis on AUS, 25 patients (78%) were not treated for NEC. Patients without pneumatosis on AUS received a significantly shorter mean duration of antibiotics compared to those with pneumatosis (3.3 days (+/- 4.8 days) vs 12.4 days (+/- 4.7 days)); p < 0.001). Of those patients not treated, none required treatment within 1 week following negative AUS.

CONCLUSION

AUS is a valuable tool for evaluating the presence or absence of pneumatosis in the setting of equivocal AXR. Absence of pneumatosis on AUS informs clinical decision making and reduces unnecessary treatment and antibiotic usage.

Evaluation of antimicrobial consumption in the neonatal population undergoing to stewardship programs: A systematic review Antimicrobial consumption in neonatal population

BACKGROUND

The indiscriminate antimicrobials use in neonatal sepsis treatment contributes to abusive consumption and optimize prescription programs are encouraged as way to reduce the inappropriate use. Thus, the objective was to evaluate the impact of intervention programs for adequate antimicrobial use (Antimicrobial Stewardship Programs - ASP) in consumption measurements of such drugs in neonatology.

METHODS

The search for articles was performed in electronic databases and manual search for citations in publications initially identified. Electronic databases searched were BVS, Cochrane Library, Embase, MEDLINE/PubMed, SciELO, Scopus and Web of Science. There was no date or period limit for including of articles. The PICO question was defined as populations of neonates admitted to neonatal intensive care units (NICU) (P) undergoing an intervention program to optimize antimicrobial therapy (I) in relation to neonates not exposed to the program (C) and the outcome obtained in antimicrobials consumption (O).

RESULTS

The initial search in databases resulted in 1223 articles. Articles were screened and sixteen original studies related to subject were selected, which conducted a quantitative approach to antimicrobials consumption for population of interest. Most articles used days of therapy (DOT) as the main measure of antimicrobial consumption and have had a high-quality rating by Newcastle Ottawa scale (NOS). All studies were carried out in local hospitals at a single-centre and most ones in high-income countries.

CONCLUSION

Of all studies resulting from search, few evaluated antimicrobial consumption in Neonatology. New studies are needed, and DOT proved to be the most adequate metric to measure consumption.

Global, regional, and national burden of neonatal sepsis and other neonatal infections, 1990-2019: findings from the Global Burden of Disease Study 2019

To provide an overview of the global, regional, and national incidence and mortality of neonatal sepsis and other neonatal infections (NS) and their change trends from 1990 to 2019, based on the data from the 2019 Global Burden of Disease study. This was a retrospective demographic analysis based on aggregated data. Annual incident cases, deaths, age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR) and their percentage changes of NS during 1990-2019 were collected from the 2019 Global Burden of Disease study. Globally, the incident cases of NS increased by 12.79% (from 5.59 million in 1990 to 6.31 million in 2019), and the deaths decreased by 12.93% (from 0.26 million in 1990 to 0.23 million in 2019). In the globe, the ASIR of NS per 100,000 population increased by 14.35% (from 85.21 in 1990 to 97.43 in 2019), and the ASMR decreased by 11.91% (from 3.97 in 1990 to 3.5 in 2019).

CONCLUSION

Increasing trends in incidence and decreasing trends in mortality of NS were observed worldwide from 1990 to 2019. More robust epidemiological research and effective health strategies are urgently needed to reduce the disease burden of neonatal sepsis worldwide.

WHAT IS KNOWN

• Neonatal sepsis has significant impacts on neonatal health, but estimates on the global burden and trends of neonatal sepsis are scarce and existing findings vary considerably.

WHAT IS NEW

• Globally, there were 6.31 million incident cases of neonatal sepsis and 0.23 million deaths due to neonatal sepsis. • Increasing trends in incidence and decreasing trends in mortality of neonatal sepsis were observed worldwide from 1990 to 2019, with the highest absolute burden in sub-Saharan Africa and Asia.

Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis

Antibiotics are the most frequently prescribed drugs in neonatal intensive care units (NICUs) due to the severity of complications accompanying neonatal sepsis. However, antimicrobial drugs are often used inappropriately due to the difficulties in diagnosing sepsis in the neonatal population. The reckless use of antibiotics leads to the development of resistant strains, rendering multidrug-resistant pathogens a serious problem in NICUs and a global threat to public health. The aim of this narrative review is to provide a brief overview of neonatal sepsis and an update on the data regarding indications for antimicrobial therapy initiation, current guidance in the empirical antimicrobial selection and duration of therapy, and indications for early discontinuation.

Quality Improvement Through Nurse-initiated Kaiser Sepsis Calculator at a County Hospital

BACKGROUND AND OBJECTIVES

Suspected early onset sepsis drives most antibiotic use in the newborn nursery. The Kaiser Sepsis Calculator (KSC) is a validated tool that safely decreases laboratory evaluation and antibiotic administration in infants aged ≥34 weeks. Our quality improvement aim was a nurse-initiated, KSC-based program to decrease blood cultures (BCx) and complete blood counts (CBC) by 10% from March 2021 to October 2021 among chorioamnionitis-exposed infants born ≥35 weeks' gestation. A secondary aim was to decrease antibiotic administration by 10%.

METHODS

The KSC was implemented for infants at University Health, a county hospital affiliate of the University of Texas Health Science Center San Antonio, with a level I nursery and level IV NICU. The multidisciplinary project included pediatric hospitalists, neonatologists, family practitioners, maternal-fetal medicine physicians, fellows, residents, and nurses. All infants born 6 months before (August 2020-January 2021) and 7 months after protocol implementation (March 2021-September 2021) were analyzed.

RESULTS

A total of 53 chorioamnionitis-exposed infants were included from the preintervention period and 51 from the postintervention period. CBC utilization decreased from 96% to 27%, BCx utilization decreased from 98% to 37%, and antibiotic utilization fell from 25% to 16%. In no cases were antibiotics prescribed against the KSC, and to our knowledge, no early onset sepsis diagnoses or infection-related hospital readmissions were missed.

CONCLUSIONS

The multidisciplinary implementation of the KSC led to a reduction in testing, exceeding our initial goal. A nurse-initiated protocol reduced BCx, CBC, and antibiotic utilization among chorioamnionitis-exposed infants.

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

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.

Gastroschisis and low incidence of early-onset infection: a case for antimicrobial stewardship

OBJECTIVE

Early onset infection (EOI) in gastroschisis is rare. Excess antibiotic exposure in neonates increases necrotizing enterocolitis and mortality. We evaluated antibiotic exposure and EOI in gastroschisis.

STUDY DESIGN

Retrospective cohort analysis between 2010-2016 in the Children's Hospital Neonatal Database. Included: Infants ≥32 weeks with gastroschisis admitted <48 h. Excluded: major anomalies or surgical intervention prior to admission.

PRIMARY OUTCOME

EOI diagnosis (<72 h).

RESULTS

In 2021 patients with gastroschisis, median gestational age was 36 weeks (IQR 35, 37). 93.9% patients received empiric antibiotics after delivery, with median 7 days duration (IQR 3, 9). Only 13 patients (0.64%) had early positive blood culture. The rate of late onset blood stream infection (7.08%) was higher, and higher in complex (18%) than simple gastroschisis (4.8%, p < 0.001).

CONCLUSION

Despite low incidence of EOI and risks of excess antibiotic exposure, neonates with gastroschisis are exposed to long courses of empiric antibiotics. These data should stimulate interinstitution work to improve antibiotic prescribing.

Neonatal Antibiotic Treatment Can Affect Stool Pattern and Oral Tolerance in Preterm Infants

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.

Population pharmacokinetics and dosing optimization of mezlocillin in neonates and young infants

OBJECTIVES

Mezlocillin is used in the treatment of neonatal infectious diseases. However, due to the absence of population pharmacokinetic studies in neonates and young infants, dosing regimens differ considerably in clinical practice. Hence, this study aimed to describe the pharmacokinetic characteristics of mezlocillin in neonates and young infants, and propose the optimal dosing regimen based on the population pharmacokinetic model of mezlocillin.

METHODS

A prospective, open-label pharmacokinetic study of mezlocillin was carried out in newborns. Blood samples were collected using an opportunistic sampling method. HPLC was used to measure the plasma drug concentrations. A population pharmacokinetic model was developed using NONMEM software.

RESULTS

Ninety-five blood samples from 48 neonates and young infants were included. The ranges of postmenstrual age and birth weight were 29-40 weeks and 1200-4000 g, respectively, including term and preterm infants. A two-compartment model with first-order elimination was developed to describe the population pharmacokinetics of mezlocillin. Postmenstrual age, current weight and serum creatinine concentration were the most important covariates. Monte Carlo simulation results indicated that the current dose of 50 mg/kg q12h resulted in 89.2% of patients achieving the therapeutic target, when the MIC of 4 mg/L was used as the breakpoint. When increasing the dosing frequency to q8h, a dose of 20 mg/kg resulted in 74.3% of patients achieving the therapeutic target.

CONCLUSIONS

A population pharmacokinetic model of mezlocillin in neonates and young infants was established. Optimal dosing regimens based on this model were provided for use in neonatal infections.

Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage

OBJECTIVE

We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015-April 2016) to 200 by December 2018.

STUDY DESIGN

We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures.

RESULTS

After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period.

CONCLUSION

Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period.

KEY POINTS

· This is a quality improvement project to reduce antibiotic usage in NICU.. · Charge nurses should take charge to reduce infections in NICU.. · Central line infections should be reduced to decrease antibiotic usage..

Effect of antibiotics in the first week of life on faecal microbiota development

BACKGROUND

Infants are frequently exposed to antibiotics (AB) in the first week of life for suspected bacterial infections. Little is known about the effect of AB on the developing intestinal microbiota. Therefore, we studied intestinal microbiota development with and without AB exposure in the first week of life in term born infants.

METHODS

We analysed the faecal microbiota from birth until 2.5 years of age by 16S rRNA gene amplicon sequencing in a cohort with 56 term born infants, exposed to AB in the first week of life (AB+) (AB for 2-3 days (AB2, n=20), AB for 7 days (AB7, n=36)), compared with 126 healthy controls (AB-). The effects of AB and duration were examined in relation to delivery and feeding mode.

RESULTS

AB+ was associated with significantly increased relative abundance of Enterobacteriaceae at 3 weeks and 1 year and a decrease of Bifidobacteriaceae, from 1 week until 3 months of age only in vaginally delivered, but not in C-section born infants. Similar deviations were noted in AB7, but not in AB2. After AB, breastfed infants had lower relative abundance of potentially pathogenic Enterobacteriaceae compared with formula fed infants and recovered 2 weeks faster towards controls.

CONCLUSIONS

AB exposure in the first week of life alters faecal microbiota development with deviations in the relative abundance of individual taxa until 1 year of age. These alterations can have long-term health consequences, which emphasises the need for future studies aiming at restoring intestinal microbiota after AB administration.

Altered Gut Structure and Anti-Bacterial Defense in Adult Mice Treated with Antibiotics during Early Life

The association between prolonged antibiotic (AB) use in neonates and increased incidence of later life diseases is not yet fully understood. AB treatment in early life alters intestinal epithelial cell composition, functioning, and maturation, which could be the basis for later life health effects. Here, we investigated whether AB-induced changes in the neonatal gut persisted up to adulthood and whether early life AB had additional long-term consequences for gut functioning. Mice received AB orally from postnatal day 10 to 20. Intestinal morphology, permeability, and gene and protein expression at 8 weeks were analyzed. Our data showed that the majority of the early life AB-induced gut effects did not persist into adulthood, yet early life AB did impact later life gut functioning. Specifically, the proximal small intestine (SI) of adult mice treated with AB in early life was characterized by hyperproliferative crypts, increased number of Paneth cells, and alterations in enteroendocrine cell-specific gene expression profiles. The distal SI of adult mice displayed a reduced expression of antibacterial defense markers. Together, our results suggest that early life AB leads to structural and physiological changes in the adult gut, which may contribute to disease development when homeostatic conditions are under challenge.

Antimicrobial defined daily dose in neonatal population

BACKGROUND

Antimicrobial defined daily dose (DDD), a standardized metric to assess antimicrobial consumption in adult population, has limitations hampering its use in neonatal patients. This study proposes an alternative DDD design applicable for neonates.

METHODS

Neonates (<1 month-old) from 6 Spanish hospitals during a 12-months period were included. Weight and weeks gestational age of each neonate were the variables collected. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication selected by the Delphi method.

RESULTS

A total of 4820 neonates were included. Mean age was 36.72 weeks of gestational age and Mean weight was 2.687kg. Standardized DDD (intravenous; oral route) for representative antimicrobials were: Amoxicillin (0.08; 0.08), amoxicillin-clavulanic acid (0.27; 0.08), ampicillin (0.27; x), cloxacillin (0.13; 0.13), penicillin G sodium (0.12), cefazolin (0.13), cefuroxime (0.27; x), cefotaxime (0.27), ceftazidime (0.27), ceftriaxone (0.13), cefepime (0.27) piperacillin-tazobactam (0.54), aztreonam (0.24), azithromycin (0.03; 0.03), clindamycin (0.04; 0.04), amikacin (0.04), gentamicin (0.01), metronidazole (0.04; 0.08), ciprofloxacin (0.04; 0.05), levofloxacin (x;x), fluconazole (0.02; 0.02), itraconazole (0.01; 0.01), fosfomycin (0.27). Restricted antimicrobials: meropenem (0.11), teicoplanin (0.02), vancomycin (0.08; 0.11), linezolid (0.08; 0.08), daptomycin (x), amphotericin B liposomal (0.01).

CONCLUSIONS

A useful method for antimicrobial DDD measurement in neonatology has been designed to monitor antimicrobial consumption in hospital settings. It should be validated in further studies and thereby included in the design for neonatal antimicrobial stewardship programs in the future.

Healthcare-Associated Infection Prevention Interventions for Neonates in Resource-Limited Settings

Healthcare-associated infections (HAIs) and antimicrobial-resistant (AMR) infections are leading causes of neonatal morbidity and mortality, contributing to an extended hospital stay and increased healthcare costs. Although the burden and impact of HAI/AMR in resource-limited neonatal units are substantial, there are few HAI/AMR prevention studies in these settings. We reviewed the mechanism of action and evidence supporting HAI/AMR prevention interventions, including care bundles, for hospitalized neonates in low- and middle-income countries (LMIC).

Association of vaginal bacterial communities and reproductive outcomes with prophylactic antibiotic exposure in a subfertile population undergoing in vitro fertilization: a prospective exploratory study

Objective:

To determine whether prophylactic azithromycin is associated with the vaginal bacterial microbiome and clinical outcomes in subfertile women undergoing in vitro fertilization (IVF).

Design:

Prospective exploratory cohort study.

Setting:

Single academic fertility center.

Patients:

Subfertile women aged 18–43 years undergoing their first IVF cycle and fresh embryo transfer.

Intervention:

Primary exposure to prophylactic azithromycin (1 g orally) once at baseline.

Main Outcome Measures:

The primary outcome was the effect of azithromycin on the vaginal microbiome compared with a no-azithromycin group at 3 time points throughout the IVF cycle (baseline, retrieval, and embryo transfer). The secondary outcomes were associations of vaginal bacterial communities with clinical outcomes.

Results:

A planned a priori exploratory cohort of 27 subjects (12 in the azithromycin treatment group and 15 in the no-azithromycin group) contributed 79 vaginal swabs for the analysis as part of an ongoing randomized, controlled noninferiority trial. No specific taxa were associated with azithromycin or pregnancy at any time point. Azithromycin did not affect alpha diversity or community stability. Although there were trends of a lower bacterial load and higher percentage of Lactobacillus species in the azithromycin group at the time of transfer, these were not statistically significant. In women who did not become pregnant, the percentage of Lactobacillus species was lower (P = .048; Hodges-Lehmann estimate of difference, 0.41; 95% confidence interval, 0.08–0.65) and the change in community composition over time was higher. The percentage of Lactobacillus species at baseline was not predictive of the percentage of Lactobacillus species at the time of embryo transfer.

Conclusions:

Prophylactic azithromycin at baseline is not associated with changes in vaginal bacterial communities. Bacterial community features at the time of embryo transfer are associated with pregnancy. Bacterial community structures at baseline are not predictive of those at the time of embryo transfer.

Clinical Trial Registration Number:

NCT03386227.

A Quality Improvement Project to Reduce Antibiotic Utilization and Ancillary Laboratory Tests in the Appraisal of Early-Onset Sepsis in the NICU

BACKGROUND

Diagnosis and treatment of early-onset sepsis (EOS) of the newborn remains a controversial issue among providers due to the non-infectious symptomology which exists in the newborn period.

METHODS

Pre/post interventional quality improvement project in a level III NICU to reduce antibiotic utilization and ancillary laboratory tests with the introduction of an evidence-based guideline for the evaluation of EOS in the NICU.

RESULTS

Primary outcome measures include mean number of empiric antibiotic treatment days and utilization rate (AUR), number of laboratory tests ordered, and incidence of unwarranted antibiotic therapy beyond the 48-h rule out period. Mean empiric antibiotic treatment days decreased from 2.94 to 1.58 days and overall antibiotic use decreased from 73.7% to 57.1%. Likewise, the mean AUR decreased from 212.5 to 147.6 days of therapy per 1000 patient days. There was an 86% decline in the number of ancillary tests and unwarranted antibiotic use beyond 48- h was reduced by 74%.

DISCUSSION

Guidelines for EOS of the newborn should include a thorough baseline evaluation of the drivers of antibiotic use to create an evidence-based foundation. Reducing unnecessary antibiotic use and EOS evaluations in a safe and effective manner have the potential to lower consumer and healthcare expenditures while improving the long-term health of the newborn in the NICU.

CONCLUSIONS

These findings emphasize the importance of implementing an evidence-based protocol for antibiotic stewardship in the NICU. With further research there is the potential to improve the healthcare of newborns while reducing expenditures in a safe, effective evaluation of EOS in the newborn population.

Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey

Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.

Antimicrobial stewardship interventions in least developed and low-income countries: a systematic review protocol

INTRODUCTION

Antimicrobial resistance (AMR) is increasing in low resource settings. It complicates the management of infectious diseases and is an increasing cause of death. This is due to, among other things, lack of health resources for appropriate diagnosis and unregulated access to antimicrobials in the public sphere. Developing context-specific interventions that enable judicious use of antimicrobials is important to curb this problem.

METHODS

We will conduct a systematic review of antimicrobial stewardship (AMS) approaches in Development Assistance Committee in least developed and low-income countries. The inclusion criteria are antimicrobial stewardship interventions in hospitalised patients of all age groups and exclusion criteria are community-based trials and studies that solely focus on viral, fungal or parasite infections. Antimicrobial stewardship interventions will be classified as structural, enabling, persuasive, restrictive or combined. Outcomes of included studies will be classified as clinical, microbiological or behavioural outcomes. The studies to be included will be randomised controlled trials, controlled before-after studies, interrupted time series trials, cohort and qualitative studies. Data will be extracted using forms adapted from the Cochrane collaboration data collection form. This systematic review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and risk of bias will be done according to the Integrated quality Criteria for Review of Multiple Study Designs.

ETHICS AND DISSEMINATION

Our findings will be presented to clinicians and policymakers, to support developing AMS protocols for low resource settings. We will publish our results in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

CRD42020210634.

The Impact of Syndromic Management of Vaginal Discharge Syndrome on Adverse Birth Outcomes in Botswana

Background

Vaginal discharge syndrome (VDS) is a common clinical diagnosis during pregnancy in Botswana; it is treated with broad-spectrum antibiotics using a syndromic approach. We evaluated associations between the syndromic management of VDS and adverse birth outcomes.

Methods

The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. Obstetric record data collected from August 2014 to March 2019 were analyzed. Chi-square tests were conducted to compare proportions of maternal characteristics and infant outcomes. To avoid immortal time bias, all analyses were conducted among women who presented to care before 24 weeks gestation, with VDS categorized as present or absent by 24 weeks gestation. Log-binomial regression models were generated to determine associations between treated VDS and infant outcomes.

Results

VDS was diagnosed in 36 731 (30.7%) pregnant women, of whom 33 328 (90.7%) received antibiotics. Adjusted analyses yielded a harmful association between treated VDS and very preterm delivery (adjusted risk ratio, 1.11; 95% CI, 1.02-1.21). This association remained when restricting to women with VDS who received the recommended antibiotic treatment regimen. Sensitivity analyses produced nonsignificant associations when women with treated VDS were compared with women without VDS who received antibiotics for other indications.

Conclusions

A clinical diagnosis of VDS is common among pregnant women in Botswana, and the majority receive antibiotics in pregnancy. Although analyses of VDS occurring later in pregnancy are precluded by immortal time bias, a modest association between treated VDS and very preterm delivery was observed among women diagnosed with VDS by 24 weeks gestation.

Antimicrobial defined daily dose in neonatal population

BACKGROUND

Antimicrobial defined daily dose (DDD), a standardized metric to assess antimicrobial consumption in adult population, has limitations hampering its use in neonatal patients. This study proposes an alternative DDD design applicable for neonates.

METHODS

Neonates (<1 month-old) from 6 Spanish hospitals during a 12-months period were included. Weight and weeks gestational age of each neonate were the variables collected. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication selected by the Delphi method.

RESULTS

A total of 4820 neonates were included. Mean age was 36.72 weeks of gestational age and Mean weight was 2.687kg. Standardized DDD (intravenous; oral route) for representative antimicrobials were: Amoxicillin (0.08; 0.08), amoxicillin-clavulanic acid (0.27; 0.08), ampicillin (0.27; x), cloxacillin (0.13; 0.13), penicillin G sodium (0.12), cefazolin (0.13), cefuroxime (0.27; x), cefotaxime (0.27), ceftazidime (0.27), ceftriaxone (0.13), cefepime (0.27) piperacillin-tazobactam (0.54), aztreonam (0.24), azithromycin (0.03; 0.03), clindamycin (0.04; 0.04), amikacin (0.04), gentamicin (0.01), metronidazole (0.04; 0.08), ciprofloxacin (0.04; 0.05), levofloxacin (x;x), fluconazole (0.02; 0.02), itraconazole (0.01; 0.01), fosfomycin (0.27). Restricted antimicrobials: meropenem (0.11), teicoplanin (0.02), vancomycin (0.08; 0.11), linezolid (0.08; 0.08), daptomycin (x), amphotericin B liposomal (0.01).

CONCLUSIONS

A useful method for antimicrobial DDD measurement in neonatology has been designed to monitor antimicrobial consumption in hospital settings. It should be validated in further studies and thereby included in the design for neonatal antimicrobial stewardship programs in the future.

Antimicrobial use for treatment of healthcare-associated infections and bacterial resistance in a reference neonatal unit

OBJECTIVE

The use of broad-spectrum antimicrobials, such as third and fourth-generation, are responsible for emergence of multidrug-resistant microorganisms in neonatal units. Furthermore, antimicrobial daily doses are not standardized in neonatology. This study aimed to investigate the association between the use of antimicrobial broad spectrum to bacterial sensitivity profile in a referral unit of neonatal progressive care.

METHODS

This is a cohort study conducted in a referral neonatal progressive care unit from January 2008 to December 2016. The data of all hospitalized neonates was collected daily. The infection criteria used were the standardized national criteria, based on definitions of Center for Diseases Control and Prevention. In this study, the use of antimicrobials was evaluated as antimicrobial-day (ATM-day) and the ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was also calculated. The study was approved by the Institutional Review Board of the Universidade Federal de Minas Gerais (ETIC 312/08 e CAAE 58973616.2.0000.5149).

RESULTS

From 2008 to 2016, 2751 neonates were hospitalized, corresponding to 60,656 patient-days. The ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was 1,3 in the first period and 4,3 in the second period (p=0,005).

CONCLUSION

It was observed that use of broad-spectrum antimicrobials, especially those with coverage for Gram-negative bacteria, was associated with an increase of multidrug-resistant bacteria.

Antibiotic Use in Very Low Birth Weight Neonates After an Antimicrobial Stewardship Program

There is insufficient data regarding antimicrobial stewardship (AS) and outcomes of very low birth weight (VLBW) neonates after AS programs. This observational, retrospective study addressed AS and outcomes of VLBW neonates admitted to an Italian level-three center. Two periods were compared: (i) baseline, before AS (January 2011-December 2012) and (ii) intervention, after AS (January 2016-December 2017). Between these two periods, procedures were put in place to inform medical and nursing staff regarding AS. There were 111 and 119 VLBW neonates in the baseline (6744 live births) and in the intervention period (5902 live births), respectively. The number of infants exposed to antibiotics (70%) during the hospital stay did not change, but the total days of therapy (DOT, median 12 vs. 5) and DOT/1000 patient days (302 vs. 215) decreased in the intervention period (p < 0.01), as well as the median duration of first antibiotic treatment (144 vs. 48 h, p < 0.01). A re-analysis of single cases of culture-proven or culture-negative sepsis failed to demonstrate any association between deaths and a delay or insufficient antibiotic use in the intervention period. In conclusion, AS is feasible in preterm VLBW neonates and antibiotic use can be safely reduced.

Antibiotic Resistance Patterns of Bacterial Isolates from Neonatal Sepsis Patients at University Hospital of Leipzig, Germany

Neonatal sepsis caused by resistant bacteria is a worldwide concern due to the associated high mortality and increased hospitals costs. Bacterial pathogens causing neonatal sepsis and their antibiotic resistance patterns vary among hospital settings and at different points in time. This study aimed to determine the antibiotic resistance patterns of pathogens causing neonatal sepsis and to assess trends in antibiotic resistance. The study was conducted among neonates with culture proven sepsis at the University Hospital of Leipzig between November 2012 and September 2020. Blood culture was performed by BacT/ALERT 3D system. Antimicrobial susceptibility testing was done with broth microdilution method based on ISO 20776-1 guideline. Data were analyzed by SPSS version 20 software. From 134 isolates, 99 (74%) were gram positive bacteria. The most common gram positive and gram negative bacteria were S. epidermidis, 51 (38%) and E. coli, 23 (17%), respectively. S. epidermidis showed the highest resistance to penicillin G and roxithromycin (90% each) followed by cefotaxime, cefuroxime, imipenem, oxacillin, and piperacillin-tazobactam (88% each), ampicillin-sulbactam (87%), meropenem (86%), and gentamicin (59%). Moreover, S. epidermidis showed raising levels of resistance to amikacin, gentamicin, ciprofloxacin, levofloxacin, moxifloxacin, and cotrimoxazol. Gram positive bacteria showed less or no resistance to daptomycin, linezolid, teicoplanin, and vancomycin. E. coli showed the highest resistance to ampicillin (74%) followed by ampicillin-sulbactam (52%) and piperacillin (48%). Furthermore, increasing levels in resistance to ampicillin, ampicillin-sulbactam, piperacillin, and cefuroxime were observed over the years. Encouragingly, E. coli showed significantly declining trends of resistance to ciprofloxacin and levofloxacin, and no resistance to amikacin, colistin, fosfomycin, gentamicin, imipenem, piperacillin-tazobactam, and tobramycin. In conclusion, this study demonstrates that gram positive bacteria were the leading causes of neonatal sepsis. Bacterial isolates were highly resistant to first and second-line empiric antibiotics used in this hospital. The high levels of antibiotic resistance patterns highlight the need for modifying empiric treatment regimens considering the most effective antibiotics. Periodic surveillance in hospital settings to monitor changes in pathogens, and antibiotic resistance patterns is crucial in order to implement optimal prevention and treatment strategies.

Procalcitonin in Preterm Neonates: A Different Threshold and Prolonged Interpretation

Objectives: To evaluate the positive threshold of PCT for neonates of <32 weeks of gestation for the diagnosis of early-onset sepsis and to determine if the level of PCT collected within 6 h of life could be used. Design: Retrospective and bicentric study from May 2016 to April 2018. Setting: Two groups were established, neonates evaluated for PCT at birth (CordPCT) and within 6 h of life (delPCT). Patients: Two hundred and sixty neonates of <32 weeks of gestation born in Nice and South Paris (Bicêtre) University Hospitals, had been evaluated for PCT level. Main Outcomes Measures: The value of the PCT positive threshold was determined for the total population and each groups thanks ROC curves. Results: The threshold level of PCT for the total population was 0.98 ng/mL. The threshold value of cordPCT group was 1.00 vs. 0.98 ng/mL for delPCT group. The area under the Receiver Operating Characteristics curve for PCT sampled in delPCT group was significantly higher than in cordPCT group (0.94 compared to 0.75). Conclusions: The threshold level of PCT was higher in this cohort of neonates of <32 weeks of gestation compared to the value generally described for term neonates. The secondary sampling PCT level seems to be usable in screening algorithm for early-onset neonatal sepsis.

Early Use of Antibiotics Is Associated with a Lower Incidence of Necrotizing Enterocolitis in Preterm, Very Low Birth Weight Infants: The NEOMUNE-NeoNutriNet Cohort Study

OBJECTIVE

To determine whether commencement of antibiotics within 3 postnatal days in preterm, very low birth weight (VLBW; ≤1500 g) infants is associated with the development of necrotizing enterocolitis (NEC).

STUDY DESIGN

Preplanned statistical analyses were done to study the association between early antibiotic treatment and later NEC development, using the NEOMUNE-NeoNutriNet cohort of VLBW infants from 13 neonatal intensive care units (NICUs) in 5 continents (n = 2831). NEC incidence was compared between infants who received early antibiotics and those who did not, with statistical adjustments for NICU, gestational age, birth weight, sex, delivery mode, antenatal steroid use, Apgar score, and type and initiation of enteral nutrition.

RESULTS

The incidence of NEC was 9.0% in the group of infants who did not receive early antibiotics (n = 269), compared with 3.9% in those who did receive early antibiotics (n = 2562). The incidence remained lower in the early antibiotic group after stepwise statistical adjustments for NICU (OR, 0.57; 95% CI, 0.35-0.94, P < .05) and other potential confounders (OR, 0.25; 95% CI, 0.12-0.47; P < .0001).

CONCLUSIONS

In this large international cohort of preterm VLBW infants, a small proportion of infants did not receive antibiotics just after birth, and these infants had a higher incidence of NEC. It is important to better understand the role of such variables as time, type, and duration of antibiotic treatment on NEC incidence, immune development, gut colonization, and antibiotic resistance in the NICU.

Metrics of neonatal antibiotic use

Responsible use of antibiotics is critical to preserve their effectiveness and to minimize adverse outcomes associated with overuse and misuse. Newborn infants are a unique population with high rates of antibiotic exposure. In order to improve neonatal antibiotic use, accurate and meaningful metrics are required. In this review, we highlight and compare existing antibiotic use metrics in detail, including definitions, current applications, advantages, and limitations of each metric, with a focus on applicability to neonatal populations. We explore future directions for identification of accurate and meaningful metrics that will allow hospitals and stakeholders to pinpoint antibiotic utilization practices that should be emulated or avoided, and ultimately improve the safety and quality of neonatal care.

Effects of β-Lactam Antibiotics on Gut Microbiota Colonization and Metabolites in Late Preterm Infants

We usually refer to the critical period for intestinal flora establishment as infancy because the infant gut microbiota is characterized by low diversity and poor stability compared with that of adults. Moreover, it is also vulnerable to interference from a variety of factors. As β-lactam antibiotics are typically used in newborn infants with infectious diseases, we used 16S rDNA sequencing and LC-MS metabolomics to analyze fecal microbes and metabolites in 16 late preterm infants with or without β-lactam antibiotic treatment. The subjects were assigned to two groups: one not treated with antibiotics and another receiving β-lactam antibiotic treatment for less than seven days. Significant changes in fecal microbes and metabolites were observed in the late preterm infants treated with antibiotics, including a reduction in the diversity of the gut microbiota overall and some beneficial bacteria such as Bacteroides, whereas some opportunistic pathogenic bacteria such as Enterococcus showed an overgrowth trend. In addition, significant changes in some crucial metabolites were observed, such as amino acids and bile acids. These findings show that treatment with β-lactam antibiotics might affect the intestinal flora and its metabolites in late preterm infants in a short time period.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Efficacy and safety of applying a neonatal early-onset sepsis risk calculator in China

AIM

To evaluate and compare the performance of the early-onset sepsis (EOS) risk calculator with procalcitonin (PCT), complete blood count (CBC) and C-reactive protein (CRP) for predicting neonatal EOS.

METHODS

This was a retrospective case-control study of neonates who were ≥34 weeks of gestation and ≤12 h of age at admission to our hospital between January 2017 and December 2018. Neonates with strictly defined EOS and those without evidence of infection were included in this study. We reviewed and collected the laboratory data and medical charts of the included neonates. The EOS risk scores for all neonates were calculated using the EOS risk calculator, and the results were analysed and compared with blood biomarkers.

RESULTS

A total of 501 neonates, including 353 infected and 148 uninfected infants, met the inclusion criteria for the study. Comparing these predictors, PCT had the best predictive value (sensitivity: 87.5%, specificity: 95.5%), closely followed by the EOS risk calculator (sensitivity: 81.16%, specificity: 93.92%). Multivariate logistic regression found that risk scores calculated by the EOS risk calculator had strong associations with EOS as an independent risk factor (odds ratio: 57.37, P < 0.05). The combination of the EOS risk calculator, PCT, CBC and CRP could increase the predictive value of the model and reach an area under the receiver operating characteristic curve of 0.987 for predicting EOS.

CONCLUSIONS

In this pilot study, applying the EOS calculator in China, the EOS risk calculator and PCT showed good predictive value compared to CBC and CRP. Risk scores from the EOS risk calculator strongly correlated with EOS, and the EOS risk calculator offered increased predictive value when used in combination with blood biomarkers.

Multicentre cross-sectional study on adverse events and good practices in maternity wards in Brazil and Mexico: same problems, different magnitude

OBJECTIVE

To evaluate the quality of delivery care in maternity wards in Brazil and Mexico based on good practices (GP) and adverse events (AE), in order to identify priorities for improvement.

DESIGN

A multicentre cross-sectional study with data collection from medical records between 2015 and 2016 to compare indicators of maternal and neonatal GP and EA based on the Safe Childbirth Checklist and standardised obstetric quality indicators. Two Brazilian and five Mexican maternity wards participated in the study. Descriptive statistics and χ² tests were performed to assess performance and significant differences between the hospitals investigated.

SAMPLING

We analysed 720 births in Brazil and 2707 in Mexico, which were selected using a systematic random sampling of 30 medical records every fortnight for 12 2-week periods in Brazil and 18 2-week periods in Mexico. We included women and their newborns, excluding those with congenital malformations.

RESULTS

The Mexican hospitals showed greater adherence to GP (58.2%) and a lower incidence of AE (12.9%) than the participating institutions in Brazil (26.8% compliance with GP and 16.0% AE). In spite of these differences, the relative importance of particular quality problems and type of AE are similar in both countries. Tertiary hospitals, caring for women at higher risk, have significantly (p<0.001) higher rates of AE (27.2% in Brazil and 29.6% in Mexico) than institutions attending women at lower risk, where the frequency of AE ranges from 4.7% to 11.2%. Differences were significant (p<0.001) for most indicators of GP and AE.

CONCLUSION

Data from outcome and process measures revealed similar types of failures in the quality of childbirth care in both countries and indicate the need of rationalising the use of antibiotics for the mother and episiotomy, encouraging greater adherence to partograph and to the use of magnesium sulfate for the treatment of severe preeclampsia/eclampsia.

Antimicrobial use in an Indonesian community cohort 0-18 months of age

BACKGROUND

Antimicrobial resistance has become a global health emergency and is contributed to by inappropriate antibiotic use in community clinical settings. The aim of this study was to evaluate the antimicrobial use pattern in infants from birth until 18 months of age in Indonesia.

METHODS

A post-hoc analysis was conducted in 1621 participants from the RV3BB Phase IIb trial conducted in Indonesia from January 2013 through July 2016. Any health events were documented in the trial as adverse events. Concomitant medication surveillance recorded all medications, including antibiotics during the 18 months of follow-up. Information included the frequency, duration of usage, formulation, classes, and their indications, including prophylactic antibiotic and perinatal use.

RESULTS

Of 1621 participants, 551 (33.99%) received at least one antibiotic for treatment of infections during the 18 months observation period. Additionally, during the perinatal period, prophylactic antibiotics were used in 1244 (76.74%) participants and antibiotics consumed in 235 mothers of participants (14.50%). A total of 956 antibiotic consumptions were recorded for 18 months follow up, 67 (7.01%) as part of antimicrobial combinations. The average duration of antibiotic course was 4.92 days. Penicillin and sulfonamides were the most common antibiotic classes consumed (38.81% and 24.48%, respectively).

CONCLUSIONS

Despite the low community consumption rate, the overuse of antibiotic in URTIs and non-bloody diarrhea in our setting represents a major opportunity for antimicrobial stewardship, particularly in early life.

Neonatal sepsis in South Asia: huge burden and spiralling antimicrobial resistance

M Jeeva Sankar and colleagues call for urgent action to improve quality of care at birth and implement antimicrobial stewardship in health facilities in South Asia to reduce neonatal deaths from sepsis

Turkish Neonatal Society guideline on neonatal infections-diagnosis and treatment

Neonatal infections are a major cause of morbidity and mortality in the first month of life, especially in developing countries. Despite advances in neonatology, neonatal infections still haves clinical importance because of nonspecific signs and symptoms, no perfect diagnostic marker, and interference with non-infectious diseases of newborns. Diagnosis is typically made by clinical and laboratory findings. Empiric antibiotic therapy should be started in a newborn with signs and symptoms of infection after cultures are taken according to the time of the signs and symptoms, risk factors, admission from community or hospital, focus of infection, and antibiotic susceptibility estimation. Treatment should be continued according to clinical findings and culture results. Intrapartum antibiotic prophylaxis, proper hand washing, aseptic techniques for invasive procedures, appropriate neonatal intensive care unit design, isolation procedures, and especially breast milk use are needed to prevent infections. The use of diagnosis and treatment protocols increases clinical success.

The association between early life antibiotic use and allergic disease in young children: recent insights and their implications

INTRODUCTION

Greater prescribing of antibiotics to infants has coincided with an epidemic of allergic disease. Through meta-analytic synthesis, accumulating evidence from prospective or database cohorts suggests a link between infant antibiotic treatment and the development of atopy. Stronger associations seen with multiple course and broad-spectrum antibiotic treatment add to biological plausibility. A major bias, confounding by indication, has been addressed in studies on antibiotic treatment of conditions which do not precede allergic disease. Areas covered: Our review provides an up-to-date synthesis of the current literature on associations between infant antibiotic exposure and future allergic disease. We discuss methods that assist in reducing study bias and look at new insights from studies of the infant gut microbiome. Expert commentary: Large-scale profiling of the gut microbiome provides a new tool for disentangling biases found in observational studies of infant antibiotic use. To date, microbial dysbiosis of the infant gut has been reported to predict allergic disease independent of antibiotic exposure up to 3 months after birth. However, these studies have not accounted for antibiotic treatment in later infancy. Continued study of the infant gut microbiome, mycobiome, or resistome will provide a closer link to antibiotic treatment or refute it as a cause of allergic disease.

Inadequate use of antibiotics and increase in neonatal sepsis caused by resistant bacteria related to health care assistance: a systematic review

Background

Technologies and life support management have enhanced the survival of preterm infants. The immune system of newborns is immature, which contributes to the occurrence of healthcare-associated infections. The overlap of several conditions with neonatal sepsis and the difficulty of diagnosis and laboratory confirmation during this period result in a tendency to over-treat neonatal sepsis. The use of antimicrobial agents is a risk factor for multidrug-resistant bacterial infections. This work aimed to perform a systematic review of the relationship between inadequate use of antimicrobial agents and increase in neonatal sepsis related to healthcare assistance, due to bacterial resistance.

Methods

Our population, exposition, comparison, outcome and study type was as follows: P: hospitalized neonates with sepsis diagnosis, E: inappropriate use of antimicrobial agents, C: adequate use of antimicrobial agents or no indication of infection, O: resistant bacterial infection, and S: original studies. We performed searches in the PubMed, Scopus, Virtual Health Library (Scielo, LILACS, and MEDLINE), and Embase without limits on time, language, and the references of the articles found. Fourteen studies were included and assessed using the Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle, and the Strengthening the Reporting of Observacional Studies in Epidemiology methodologies.

Results

All studies found were observational and started with a low-quality evidence level in the Grading of Recommendations, Assessment, Development, and Evaluation.

Conclusions

Despite their low-quality evidence, the studies demonstrated the association between inadequate use of antimicrobial agents and increase of neonatal resistant bacterial healthcare-associated infections in neonatal units. However, there is significant difficulty in conducting high-quality studies in this population due to ethical issues tied to randomized trials. Therefore, new studies should be encouraged to recommend adequate treatment of newborns without increasing the risk of healthcare-associated infections by multidrug-resistant bacteria.

Implementation and Evaluation of the Early-Onset Sepsis Risk Calculator in a High-Risk University Nursery

There is growing interest in the Kaiser early-onset sepsis (EOS) risk calculator though institutions are hesitant to deviate from the Centers for Disease Control and Prevention guidelines and implement this in their hospitals. We describe the process of implementing routine use of the risk calculator in term and late preterm newborns delivered to mothers with chorioamnionitis in a level III neonatal intensive care unit (NICU). A retrospective chart review of infants delivered to mothers with chorioamnionitis from 2011 to 2014 was performed. Implementation of routine use of the calculator began in January 2015; preintervention and postintervention data were analyzed after a 9-month period of routine use. Following implementation, NICU admission rates, number of blood cultures drawn, and rates of antibiotic use dropped by 54%, 42%, and 59%, respectively ( P < .001). No negative outcomes were reported. In this article, we describe how the calculator was safely implemented in our NICU while decreasing the number of interventions.

Temporal Trends and Center Variation in Early Antibiotic Use Among Premature Infants

IMPORTANCE

Premature infants are frequently administered empirical antibiotic therapy at birth. Early and prolonged antibiotic exposures among infants without culture-confirmed infection have been associated with increased risk of adverse outcomes.

OBJECTIVE

To examine early antibiotic use among premature infants over time and across hospitals in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a comprehensive administrative database of inpatient encounters from 297 academic and community hospitals across the United States to examine data concerning very low-birth-weight (VLBW) infants (<1500 g), including extremely low-birth-weight (ELBW) infants (<1000 g), who were admitted to the neonatal intensive care unit and survived for at least 1 day. Data collection took place in November 2015 and analysis took place from February 2016 to November 2016.

EXPOSURES

Antibiotic initiation within the first 3 days of age and subsequent antibiotic administration for more than 5 days.

MAIN OUTCOMES AND MEASURES

Temporal trends in early antibiotic initiation and duration from 2009 to 2015, and center variation in early antibiotic use from 2014 to 2015.

RESULTS

We identified 40 364 VLBW infants (20 447 female [50.7%]) who survived for at least 1 day, including 12 947 ELBW infants, from 297 centers. The majority of premature infants had early antibiotic initiation (31 715 VLBW infants [78.6%] and 11 264 ELBW infants [87.0%]), and no differences were observed over time in temporal trend analyses (P = .12 for VLBW and P = .52 for ELBW). The annual risk difference in the proportion of VLBW infants administered early antibiotic therapy ranged from -0.75% (95% CI, -1.61% to 0.11%) to -0.87% (95% CI, -2.04% to 0.30%); in ELBW infants the annual risk difference ranged from -0.34% (95% CI, -1.28% to 0.61%) to -0.38% (95% CI, -1.61% to 0.85%). There was a small but significant decrease over time in the rate of prolonged antibiotic duration for VLBW infants (P = .02), but not for ELBW infants (P = .22). The annual risk difference in the proportion of VLBW infants with prolonged antibiotic duration ranged from -0.94% (95% CI, -1.65% to -0.23%) to -1.08% (95% CI, -2.00% to -0.16%); in ELBW infants the annual risk difference ranged from -0.72% (95% CI, -1.83% to 0.39%) to -0.75% (95% CI, -1.96% to 0.46%). We also observed variation in early antibiotic exposures across centers. Sixty-nine of 113 centers (61.1%) started antibiotic therapy for more than 75% of VLBW infants, and 56 of 66 centers (84.8%) started antibiotic therapy for more than 75% of ELBW infants. The proportion of VLBW and ELBW infants administered prolonged antibiotics ranged from 0% to 80.4% and 0% to 92.0% across centers, respectively.

CONCLUSIONS AND RELEVANCE

Most premature infants in this study received empirical early antibiotic therapy with little change over a recent 7-year period. The variability in exposure rates across centers, however, suggests that neonatal antimicrobial stewardship efforts are warranted to optimize antibiotic use for VLBW and ELBW infants.