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Mazabanda López DA, Urquia Martí L, Reyes Suárez D, Siguero Onrubia M, Borges Luján M, García-Muñoz Rodrigo F. Improved efficiency in the management of newborns with infectious risk factors by the sepsis risk calculator and clinical observation. J Pediatr (Rio J) 2024; 100:100-107. [PMID: 37758173 PMCID: PMC10751711 DOI: 10.1016/j.jped.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE To evaluate the efficiency of the sepsis risk calculator and the serial clinical observation in the management of late preterm and term newborns with infectious risk factors. METHOD Single-center, observational, two-phase cohort study comparing the rates of neonates born ≥35 weeks' gestation, ≥2000 g birthweight, and without major congenital anomalies, who were screened and/or received antibiotics for early-onset neonatal sepsis risk at our center during two periods, before (January/2018-June/2019) and after (July/2019-December/2020) the implementation of the sepsis risk calculator. RESULTS A total of 1796 (Period 1) and 1867 (Period 2) patients with infectious risk factors were included. During the second period, tests to rule out sepsis were reduced by 34.0 % (RR, 95 %CI): 0.66 (0.61, 0.71), blood cultures by 13.1 %: 0.87 (0.77, 0.98), hospital admissions by 13.5 %: 0.86 (0.76, 0.98) and antibiotic administration by 45.9 %: 0.54 (0.47, 0.63). Three cases of early-onset neonatal sepsis occurred in the first period and two in the second. Clinical serial evaluation would have detected all true cases. CONCLUSIONS The implementation of a sepsis risk calculator in the management of newborns ≥35 weeks GA, ≥2000 g birthweight, without major congenital anomalies, with infectious risk factors is safe and adequate to reduce laboratory tests, blood cultures, hospital admissions, and antibiotics administration. Serial clinical observation, in addition, could be instrumental to achieve or even improve this goal.
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Affiliation(s)
| | - Lourdes Urquia Martí
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Desiderio Reyes Suárez
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Marta Siguero Onrubia
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Moreyba Borges Luján
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Fermín García-Muñoz Rodrigo
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain.
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Gardner BD, Mitchell L. Risk Stratification to Support Antibiotic Stewardship and Breastfeeding Exclusivity in a Military Treatment Facility. Nurs Womens Health 2023; 27:201-210. [PMID: 37080249 DOI: 10.1016/j.nwh.2023.01.009] [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: 11/03/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE To safely reduce unnecessary antibiotic exposure in neonates exposed to chorioamnionitis and inadequately treated Group B Streptococcus (GBS) using the early-onset sepsis (EOS) calculator for risk stratification and a 36-hour antibiotic duration. DESIGN Evidence-based quality improvement initiative. SETTING/LOCAL PROBLEM Obstetric service at a midsized military treatment facility with approximately 2,000 births annually and no standard process for neonatal EOS risk assessment. PARTICIPANTS Clinical nurse specialist, physicians, nursing leadership, unit-level nursing champions, and nurses assigned to the mother-baby and labor and delivery units. INTERVENTION/MEASUREMENTS An interdisciplinary working group created a protocol to institute an EOS risk assessment calculator, a note for the electronic heath record, and interdisciplinary education for all staff providing care to neonates in our facility. RESULTS Before implementation of the EOS calculator, 97.6% of neonates exposed to chorioamnionitis or inadequate maternal GBS treatment received antibiotics; after implementation, the mean rate dropped to 32%. Exclusive breastfeeding rates before discharge in neonates exposed to chorioamnionitis or inadequate maternal GBS treatment also increased during this time, from 40% to a mean of 89%. After implementation, there were no readmissions to our institution for culture-proven sepsis within 14 days of discharge. CONCLUSION Multidisciplinary team-led implementation of the EOS calculator and of shortened antibiotic duration were associated with safely reduced antibiotic exposure in well-appearing neonates exposed to chorioamnionitis and GBS. In addition, dramatically improved rates of exclusive breastfeeding at discharge were observed in this population.
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Rallis D, Giapros V, Serbis A, Kosmeri C, Baltogianni M. Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis. Antibiotics (Basel) 2023; 12:antibiotics12030508. [PMID: 36978375 PMCID: PMC10044400 DOI: 10.3390/antibiotics12030508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
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.
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Affiliation(s)
- Dimitrios Rallis
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
- Correspondence: ; Tel.: +30-(26)-51099326
| | - Anastasios Serbis
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Chrysoula Kosmeri
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
| | - Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece
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Montaner Ramón A, Castilla Fernández Y, Frick MA, Camba Longueira F, Céspedes Domínguez MC, Ribes Bautista C, Castillo Salinas F. How to assess early-onset neonatal sepsis? Comparison of three detection strategies. An Pediatr (Barc) 2023; 98:92-98. [PMID: 36710085 DOI: 10.1016/j.anpede.2022.10.009] [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: 05/24/2022] [Accepted: 10/19/2022] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Early-onset neonatal sepsis (EONS) can cause significant morbidity and mortality, especially if it is not detected early. Given the decrease in its incidence in the past few decades, it is important to find a balance between reducing the use of diagnostic tests and continuing to detect affected patients. We compared 3 detection strategies in patients with risk factors (RFs) for infection: laboratory screening (S1), the Neonatal Sepsis Risk Calculator (S2) and clinical observation (S3). PATIENTS AND METHODS Retrospective observational study in neonates born at 34 weeks of gestation or later and with RFs or symptoms compatible with EONS. We analysed outcomes in our unit with the use of laboratory screening (S1) and compared them with the other two strategies (S2 and S3) to contemplate whether to modify our protocol. RESULTS The study included 754 patients, and the most frequent RFs were prolonged rupture of membranes (35.5%) and maternal colonization by Streptococcus agalactiae (38.5%). Strategies S2 and S3 would decrease the performance of laboratory tests (S1, 56.8% of patients; S2, 9.9%; S3, 22.4%; P < 0.01), hospital admissions (S1, 11%; S2, 6.9%; S3, 7.9%; P < 0.01) and the use of antibiotherapy (S1, 8.6%; S2, 6.7%; S3, 6.4%; P < 0.01). Sepsis was diagnosed in 13 patients, and it would have been detected with S2 and S3 except in 1 patient who had asymptomatic bacteriemia by Enterococcus faecalis. No patient with mild and self-limited symptoms in whom antibiotherapy was not started received a diagnosis of sepsis later on. CONCLUSION Close clinical observation seems to be a safe option and could reduce the use of diagnostic tests, hospital admission and unnecessary antibiotherapy. The watchful waiting approach in patients with mild and self-limiting symptoms in the first hours post birth does not appear to be associated with failure to identify sepsis.
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Affiliation(s)
| | | | - María Antoinette Frick
- Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitari Vall D'hebron, Barcelona, Spain
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Hadfield BR, Rowley J, Puyol F, Johnson MA, Ali M, Neuhoff BK, Lyman R, Saravia A, Svatek M, Sherburne K, Cantey JB. Quality Improvement Through Nurse-initiated Kaiser Sepsis Calculator at a County Hospital. Hosp Pediatr 2023; 13:31-38. [PMID: 36537146 DOI: 10.1542/hpeds.2022-006554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Brandon R Hadfield
- Division of Neonatology, Departments of Pediatrics and.,University of Texas Health San Antonio, San Antonio, Texas
| | - Justin Rowley
- University of Texas Health San Antonio, San Antonio, Texas
| | - Franz Puyol
- University of Texas Health San Antonio, San Antonio, Texas
| | | | - Murtaza Ali
- University of Texas Health San Antonio, San Antonio, Texas
| | - Barbara K Neuhoff
- Obstetrics and Gynecology.,University of Texas Health San Antonio, San Antonio, Texas
| | - Rachel Lyman
- University of Texas Health San Antonio, San Antonio, Texas
| | - Alma Saravia
- Division of Neonatology, Department of Pediatrics, University Health System, San Antonio, Texas
| | - Mandy Svatek
- University of Texas Health San Antonio, San Antonio, Texas
| | | | - Joseph B Cantey
- Division of Neonatology, Departments of Pediatrics and.,Division of Allergy, Immunology, and Infectious Diseases.,University of Texas Health San Antonio, San Antonio, Texas
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¿Cómo evaluar la sepsis neonatal de inicio precoz? Estudio comparativo de tres estrategias de detección. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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7
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Dsouza V, Kothari N, Mishra U, Jani P, Maheshwari R, Shah D, D'Cruz D, Baird J, Luig M. Reducing antibiotic use in asymptomatic term infants exposed to maternal chorioamnionitis: Predictive role of sepsis risk calculator. J Paediatr Child Health 2022; 58:1958-1963. [PMID: 35869737 DOI: 10.1111/jpc.16128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
AIM The sepsis risk calculator (SRC) has been shown to reduce empirical antibiotic usage in neonates at risk of early-onset sepsis without increasing adverse clinical outcomes. However, its use for categorising and improving identification of at-risk neonates exposed to chorioamnionitis in the local population has not been reported. This study compares the management guided by the SRC to our unit's clinical practice of administering empirical antibiotics to all term neonates (born ≥37 weeks gestation), symptomatic and asymptomatic, who were exposed to chorioamnionitis, and evaluates the performance of the SRC in managing asymptomatic term neonates exposed to chorioamnionitis. METHODS This single-centre retrospective study identified 178 eligible term neonates exposed to chorioamnionitis over a 17-month study period. Relevant demographic and clinical information on the mother-infant dyad was collected. The SRC was executed retrospectively in the study cohort. Descriptive statistics were used for reporting the findings. RESULTS The mean gestational age was 39 (standard deviation, SD 1) weeks, and the mean birth weight was 3472 (SD 482) g. Of the 178 neonates, 136 (76%) were asymptomatic and received empirical antibiotic therapy for 2 days (mean). Based on management recommendations from the SRC, empirical antibiotic therapy could have been avoided in 98% of asymptomatic neonates; 88% could have been managed by observation alone, avoiding mother-infant separation. No neonate died or had a positive blood culture result. CONCLUSIONS The SRC could reduce antibiotic exposure in asymptomatic neonates exposed to chorioamnionitis. It could assist clinicians to categorise risk in neonates exposed to chorioamnionitis.
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Affiliation(s)
- Vanessa Dsouza
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Nakul Kothari
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Umesh Mishra
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Pranav Jani
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh Maheshwari
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Dharmesh Shah
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Daphne D'Cruz
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jane Baird
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Melissa Luig
- Neonatal Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
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Rugolo LMSDS, Bentlin MR, Almeida MFBD, Guinsburg R, Carvalho WBD, Marba STM, Almeida JHCLD, Luz JH, Procianoy RS, Duarte JLMB, Anchieta LM, Ferreira DMDLM, Alves Júnior JMS, Diniz EMDA, Santos JPFD, Gimenes CB, Silva NMDME, Ferrari LL, Silva RPGVCD, Meneses J, Gonçalves-Ferri WA, Vale MSD, Brine H, Weiner GM. Risk Perception and Decision Making about Early-Onset Sepsis among Neonatologists: A National Survey. Am J Perinatol 2022; 39:1117-1123. [PMID: 33341925 DOI: 10.1055/s-0040-1721691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Many newborns are investigated and empirically treated for suspected early-onset sepsis (EOS). This study aimed to describe neonatologists' self-identified risk thresholds for investigating and treating EOS and assess the consistency of these thresholds with clinical decisions. STUDY DESIGN Voluntary online survey, available in two randomized versions, sent to neonatologists from 20 centers of the Brazilian Network on Neonatal Research. The surveys included questions about thresholds for investigating and treating EOS and presented four clinical scenarios with varying calculated risks. In survey version A, only the scenarios were presented, and participants were asked if they would order a blood test or start antibiotics. Survey version B presented the same scenarios and the risk of sepsis. Clinical decisions were compared between survey versions using chi-square tests and agreement between thresholds and clinical decisions were investigated using Kappa coefficients. RESULTS In total, 293 surveys were completed (145 survey version A and 148 survey version B). The median risk thresholds for blood test and antibiotic treatment were 1:100 and 1:25, respectively. In the high-risk scenario, there was no difference in the proportion choosing antibiotic therapy between the groups. In the moderate-risk scenarios, both tests and antibiotics were chosen more frequently when the calculated risks were included (survey version B). In the low-risk scenario, there was no difference between survey versions. There was poor agreement between the self-described thresholds and clinical decisions. CONCLUSION Neonatologists overestimate the risk of EOS and underestimate their risk thresholds. Knowledge of calculated risk may increase laboratory investigation and antibiotic use in infants at moderate risk for EOS. KEY POINTS · Neonatologists overestimate the risk of EOS.. · There is wide variation in diagnostic/treatment thresholds for EOS.. · Clinical decision on EOS is not consistent with risk thresholds.. · Knowledge of risk may increase investigation and treatment of EOS..
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Affiliation(s)
| | - Maria Regina Bentlin
- Division of Neonatology, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista-UNESP, Botucatu, Brazil
| | | | - Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Jorge Hecker Luz
- Department of Pediatrics, Hospital São Lucas-Faculdade de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Renato Soibelmann Procianoy
- Division of Neonatology, Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre -HCPA, Porto Alegre, Brazil
| | - José Luiz Muniz Bandeira Duarte
- Department of Pediatrics, Hospital Universitário Pedro Ernesto-Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leni Márcia Anchieta
- Division of Neonatology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Edna Maria de Albuquerque Diniz
- Division of Neonatology, University of São Paulo, Brazil da Universidade de São Paulo, Hospital Universitário, São Paulo, Brazil
| | | | | | | | - Lígia Lopes Ferrari
- Department of Pediatrics, Hospital Universitário-Universidade Estadual de Londrina, Londrina, Brazil
| | | | - Jucille Meneses
- Department of Pediatrics, Instituto de Medicina Integral Professor Fernando Figueira, Recife, Brazil
| | - Walusa Assad Gonçalves-Ferri
- Department of Pediatrics, Faculdade de Medicina de Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Holly Brine
- Departent of Pediatrics, Promedica Toledo Children's Hospital, University of Toledo, Ohio
| | - Gary M Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, Michigan
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Hershkovich–Shporen C, Guri A, Gluskina T, Flidel‐Rimon O. Centers for disease control and prevention guidelines identified more neonates at risk of early-onset sepsis than the Kaiser-Permanente calculator. Acta Paediatr 2022; 111:767-771. [PMID: 34932840 DOI: 10.1111/apa.16232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 01/25/2023]
Abstract
AIM Our aim was to retrospectively compare how many cases of early-onset sepsis (EOS) would have been predicted by the the Kaiser-Permanente (KP) calculator and the United States Centers for Disease Control and Prevention (CDC) guidelines. METHODS This observational retrospective cohort study comprised 50 newborn infants with documented EOS who were born at the Kaplan Medical Centre, Israel, between 2001 and 2018. We retrospectively evaluated whether the KP calculator and the CDC recommendations would have recommended antibiotic treatment if they had been implemented within four hours of birth. RESULTS EOS was diagnosed in 50 of the 109 877 infants born from 34 weeks of gestation. By four hours of birth, 18 were symptomatic, five had an equivocal clinical status, and 27 were asymptomatic. The KP calculator would have recommended antibiotic treatment for 19 (38%) neonates: 18 who were symptomatic and one who was initially asymptomatic. The CDC guidelines would have recommended antibiotic treatment for 27 (54%) nenonates: those 19 plus all 5 with equivocal status and other 3 who were asymptomatic. CONCLUSION Using the CDC guidelines would have identified more equivocal and asymptomatic EOS cases within four hours of birth than the KP calculator. Enhanced observation is recommended when using the KP calculator.
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Affiliation(s)
- Calanit Hershkovich–Shporen
- Department of Neonatology Kaplan Medical Centre Rehovot Israel
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
| | - Alex Guri
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
- Department of Paediatrics Kaplan Medical Centre Rehovot Israel
- Infectious Diseases Unit Kaplan Medical Centre Rehovot Israel
| | - Tatiana Gluskina
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
- Department of Paediatrics Kaplan Medical Centre Rehovot Israel
| | - Orna Flidel‐Rimon
- Department of Neonatology Kaplan Medical Centre Rehovot Israel
- The Hebrew University School of Medicine Hebrew University and Hadassah Medical Centre Jerusalem Israel
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Oak S, Stempowski M, Frank E. Implementation of the Early-Onset Sepsis Risk Calculator at a Community Level I Nursery. Clin Pediatr (Phila) 2022; 61:259-265. [PMID: 34889151 DOI: 10.1177/00099228211064742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this retrospective cohort study was to decrease the frequency of laboratory draws and the number of neonates receiving empiric antibiotics who are born to mothers with chorioamnionitis from 100% to 50% 6 months following implementation of the sepsis risk calculator (SRC) at a level 1 community nursery. Data were compared pre- and post-implementation of the SRC using the Fischer's exact test. The rate of intravenous (IV) antibiotic use decreased from 93% to 7% (P < .0001). The rate of blood culture collection decreased from 100% to 46% (P < .0001). With implementation of the SRC, administration of IV antibiotics, laboratory draws, and IV placement significantly decreased without increasing rates of early-onset sepsis in our patient population. Our study demonstrated that the SRC can be effectively and safely implemented at a level 1 community-based newborn nursery, resulting in a decrease in unnecessary medical treatment without negative patient outcomes.
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Affiliation(s)
- Sharmila Oak
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Melanie Stempowski
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Erin Frank
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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11
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Capin I, Hinds A, Vomero B, Roth P, Blau J. Are Early-Onset Sepsis Evaluations and Empiric Antibiotics Mandatory for All Neonates Admitted with Respiratory Distress? Am J Perinatol 2022; 39:444-448. [PMID: 32947642 DOI: 10.1055/s-0040-1717070] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the success and safety of an antimicrobial stewardship protocol for neonates admitted with respiratory distress at birth. STUDY DESIGN A retrospective cohort analysis of all infants admitted to the neonatal intensive care unit (NICU) with respiratory distress from January 2013 to February 2018 was conducted. In April 2016, an antimicrobial stewardship protocol was implemented, dividing neonates into two groups: maternal indications for delivery (no infectious risk factors for early-onset sepsis [EOS]) and fetal indications (risk factors present) for delivery. Neonates with risk factors for EOS were started on empiric antibiotics, those who lacked risk factors were observed. Paired sample t-test and descriptive statistics were used to compare the pre- and postprotocol implementation. RESULTS There were no missed cases of EOS in our study. Management with empiric antibiotics decreased from 95 to 41% of neonates with respiratory distress after initiation of the protocol. Newborns with a lower mean (±standard errors of the mean [SEM]) gestational age were more likely to receive empiric antibiotics (35.1 ± 0.4 [range: 23-42 weeks] vs. 37.7 ± 0.2 weeks [range: 24-42 weeks]; p < 0.05). Similar findings were seen for neonates with lower mean birth weights (2,627 ± 77 [range: 390-5,440 g] vs. 3,078 ± 51 g [range: 620-6,260 g]; p < 0.05). CONCLUSION The antibiotic stewardship protocol safely reduces the administration of empiric antibiotics to symptomatic neonates without missing any cases of sepsis. KEY POINTS · Newborns born with respiratory distress often receive broad-spectrum antibiotics upon NICU admission.. · An antibiotic stewardship program was created for this population and considered perinatal risk factors for sepsis when determining whether antibiotics were indicated.. · This antibiotic stewardship program was safe and effective, significantly reducing antibiotic use without missing any cases of sepsis..
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Affiliation(s)
- Ivana Capin
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Autumn Hinds
- SUNY Downstate College of Medicine, Brooklyn, New York
| | - Bridgit Vomero
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Philip Roth
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jonathan Blau
- Department of Pediatrics, Division of Neonatology, Staten Island University Hospital, Northwell Health, Staten Island, New York.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Abstract
Chorioamnionitis or intrauterine inflammation is a frequent cause of preterm birth. Chorioamnionitis can affect almost every organ of the developing fetus. Multiple microbes have been implicated to cause chorioamnionitis, but "sterile" inflammation appears to be more common. Eradication of microorganisms has not been shown to prevent the morbidity and mortality associated with chorioamnionitis as inflammatory mediators account for continued fetal and maternal injury. Mounting evidence now supports the concept that the ensuing neonatal immune dysfunction reflects the effects of inflammation on immune programming during critical developmental windows, leading to chronic inflammatory disorders as well as vulnerability to infection after birth. A better understanding of microbiome alterations and inflammatory dysregulation may help develop better treatment strategies for infants born to mothers with chorioamnionitis.
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Beck T, Sloane AJ, Carola DL, McElwee D, Edwards C, Bell-Carey B, Leopold K, Greenspan JS, Aghai ZH. Management of well appearing infants born to afebrile mothers with inadequate GBS prophylaxis: A retrospective comparison of the three approaches recommended by the COFN. J Neonatal Perinatal Med 2021; 15:297-302. [PMID: 34806622 DOI: 10.3233/npm-210798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36-48 hours. The second approach recommends serial physical examinations and vital signs for 36-48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS. STUDY DESIGN This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition. RESULTS A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS. CONCLUSION The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.
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Affiliation(s)
- T Beck
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - A J Sloane
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - D L Carola
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - D McElwee
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - C Edwards
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - B Bell-Carey
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - K Leopold
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - J S Greenspan
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
| | - Z H Aghai
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, United States
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Intrapartum and Postpartum Management of Intra-amniotic Infection. Obstet Gynecol Surv 2021; 76:114-121. [PMID: 33625521 DOI: 10.1097/ogx.0000000000000867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Intra-amniotic infection (IAI) is a common condition with potentially devastating maternal and neonatal complications. However, there are incomplete data regarding the most effective antimicrobial treatment regimen for this condition. Objective This article aims to review the current evidence and recommendations for intrapartum and postpartum management of IAI. Evidence Acquisition Original research articles, review articles, and guidelines on IAI were reviewed. Results Numerous known risk factors for IAI exist, some of which are modifiable. Serious neonatal complications can result from exposure to IAI including increased risk of preterm birth and neonatal death. Possible maternal complications include increased risk of cesarean delivery, postpartum hemorrhage, and postpartum endometritis. Antibiotics are the mainstay of treatment for IAI for both mothers and neonates, although there is no consensus on which antimicrobial agents are best and the appropriate duration of therapy. Conclusions and Relevance Monitoring patients for signs of IAI, proper treatment, and communication of the diagnosis with the pediatric team are essential for preventing maternal and neonatal complications of IAI. More research is needed to determine the proper treatment regimens for both mothers diagnosed with IAI and their neonates.
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Retrospective cohort study of neonatal early onset of sepsis and the role of the EOS calculator in a level II nursery. Pediatr Neonatol 2021; 62:512-521. [PMID: 34092529 DOI: 10.1016/j.pedneo.2021.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/31/2021] [Accepted: 05/10/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis is a major cause of mortality and morbidity in neonates. With the improvement in health care standards, the incidence of neonatal Early Onset Sepsis (EOS) has reduced significantly. A recent Web-based EOS-calculator has been introduced with the aim to reduce the use of IV antibiotics in neonates. The role of the EOS-calculator has yet to be ascertained in this regional Special Care Nursery (SCN) in Western Australia. This study aims at examining the local incidence of culture proven EOS and the role of the EOS calculator. METHOD It is a retrospective study examining all newborns ≥35 weeks gestation throughout 2019 (Jan-Dec 2019) who received IV-antibiotics. The local incidence of culture-proven EOS was established and applied onto the EOS calculator. The recommended management by the EOS-calculator was cross-examined with the local EOS guideline. Overall proportion of reduction in IV antibiotics use was formulated. Other relevant laboratory data extracted was analysed with Pearson's correlation test with the EOS scores. RESULTS Total included sample was n = 252 with an annual birth of 1880s indicating 13.4% of all neonates born throughout year 2019 was treated with IV antibiotics. The local incidence of culture-proven EOS was 0.5/1000. By applying the EOS-calculator, a significant reduction of IV antibiotics usage from 13.4% to 3.9% (z value 10.4, p < 0.0001) could be achieved in this cohort. Sixty three percent of neonates who received IV antibiotics in this cohort were classified as 'clinically well' based on the EOS-calculator. CONCLUSION The EOS-calculator could reduce the use of IV antibiotics in the neonatal population significantly in this regional SCN (from 13.4% to 3.9%). Judicial use of IV antibiotics is imperative as part of the holistic care for the neonates. Implementation of the EOS-calculator must be done strategically considering the local incidence of EOS and other health care policies.
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Abstract
The changing epidemiology of early-onset neonatal sepsis among term infants has required reappraisal of approaches to management of newborn infants at potential risk. As this is now a rare disease, new strategies for reduction in diagnostic testing and empirical treatment have been developed. Adoption and refinement of these strategies should be a priority for all facilities where babies are born.
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Affiliation(s)
- Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sagori Mukhopadhay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Adam Frymoyer
- Department of Pediatrics-Neonatology, Stanford University, 453 Quarry Road, MC: 5660, Palo Alto, CA 94304, USA
| | - William E Benitz
- Department of Pediatrics-Neonatology, Stanford University, 453 Quarry Road, MC: 5660, Palo Alto, CA 94304, USA
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Evaluation of Implementation of Early-Onset Sepsis Calculator in Newborns in Israel. J Pediatr 2021; 234:71-76.e2. [PMID: 33857468 DOI: 10.1016/j.jpeds.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/21/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the recommendations based on the early-onset sepsis (EOS) calculator in the first 2 years of its implementation in Israel. STUDY DESIGN Prospective 2-year surveillance of a cohort of infants born at gestational age of ≥34 weeks in Bnai Zion Medical Center, who were evaluated using the EOS calculator because of peripartum risk factors. RESULTS We evaluate 1146 newborns with peripartum risk factors using the EOS calculator. The percentage of infants who had laboratory evaluation decreased to 4.6%, and the EOS calculator recommended empiric antibiotic therapy in only 2.2%. During the study period, there were 4 early-onset infections (EOS incidence of 0.6 in 1000 live births). Three had group B streptococcus (GBS) and one had Escherichia coli infection. Only 2 of these infants had perinatal risk factors and the EOS calculator identified them and recommended laboratory evaluation and empiric antibiotics. However, 2 infants with GBS EOS had no perinatal risk factors or clinical symptoms at delivery, and were discovered clinically at older ages. CONCLUSIONS The Israeli EOS calculator-based guidelines seem to be appropriate and are associated with less laboratory evaluations, and little use of empiric antibiotics. Concerns are related to the current recommendation of no GBS universal screening in Israel, and the inability of the calculator-based approach to identify GBS EOS in infants born to mothers with unknown GBS who have no peripartum risk factors before presentation of clinical symptoms.
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A comparison between risk-factor guidance for neonatal early-onset sepsis and Kaiser Permanente sepsis risk calculator in a Greek cohort. Early Hum Dev 2021; 155:105331. [PMID: 33607601 DOI: 10.1016/j.earlhumdev.2021.105331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of neonates with early-onset sepsis (EOS) is based on maternal risk factors and infant clinical indications. An online sepsis risk calculator (SRC) has been established taking into consideration how clinical appearance modifies the initial risk for EOS. AIMS To compare our clinical practice based on risk-factor guidance with that projected through the application of the SRC. STUDY DESIGN Retrospective cohort study. METHODS All neonates ≥34 weeks' gestation, during 01/2019-8/2020. The SRC was applied retrospectively to determine the recommendation. EOS was defined based on a positive blood or cerebrospinal fluid culture-proven infection within 72 h of age. Clinical sepsis was defined according to the European Medicine Agency criteria. OUTCOME MEASURES Differences on antibiotic administration and management. RESULTS Overall, 2084 infants were identified, of whom 150 (7%) received antibiotics. Of them, 34 infants were diagnosed with clinical sepsis, while one was diagnosed with culture positive-proven EOS. Applying SRC, 87 (4%) infants would have received antibiotics. Clinical sepsis was diagnosed in 29 infants, while one infant had culture positive-proven EOS. Sixty-seven of 150 (45%) infants that received antibiotics would not have been treated based on SRC; five infants that developed clinical sepsis would have been missed with SRC. A 99.7% agreement between both guidance was found regarding infants not indicated for antibiotics. SRC application led to an absolute reduction of antibiotic administration by 2.93% (95% CI 2.19-3.75), p < 0.0001. CONCLUSIONS The adoption of SRC would have significantly reduced antibiotic usage; however, a significant portion of cases with clinical EOS would have been missed.
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Laccetta G, Ciantelli M, Tuoni C, Sigali E, Miccoli M, Cuttano A. Early-onset sepsis risk calculator: a review of its effectiveness and comparative study with our evidence-based local guidelines. Ital J Pediatr 2021; 47:73. [PMID: 33766096 PMCID: PMC7992929 DOI: 10.1186/s13052-021-01028-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/15/2021] [Indexed: 12/20/2022] Open
Abstract
Background According to most early-onset sepsis (EOS) management guidelines, approximately 10% of the total neonatal population are exposed to antibiotics in the first postnatal days with subsequent increase of neonatal and pediatric comorbidities. A review of literature demonstrates the effectiveness of EOS calculator in reducing antibiotic overtreatment and NICU admission among neonates ≥34 weeks’ gestational age (GA); however, some missed cases of culture-positive EOS have also been described. Methods Single-center retrospective study from 1st January 2018 to 31st December 2018 conducted in the Division of Neonatology at Santa Chiara Hospital (Pisa, Italy). Neonates ≥34 weeks’ GA with birth weight ≤ 1500 g, 34–36 weeks’ GA neonates with suspected intraamniotic infection and neonates ≥34 weeks’ GA with three clinical signs of EOS or two signs and one risk factor for EOS receive empirical antibiotics. Neonates ≥34 weeks’ GA with risk factors for EOS or with one clinical indicator of EOS undergo serial measurements of C-reactive protein and procalcitonin in the first 48–72 h of life; they receive empirical antibiotics in case of abnormalities at blood exams with one or more clinical signs of EOS. Two hundred sixty-five patients at risk for EOS met inclusion criteria; they were divided into 3 study groups: 34–36 weeks’ GA newborns (n = 95, group A), ≥ 37 weeks’ GA newborns (n = 170, group B), and ≥ 34 weeks’ GA newborns (n = 265, group A + B). For each group, we compared the number of patients for which antibiotics would have been needed, based on EOS calculator, and the number of the same patients we treated with antibiotics during the study period. Comparisons between the groups were performed using McNemar’s test and statistical significance was set at p < 0.05; post-hoc power analysis was carried out to evaluate the sample sizes. Results 32/265 (12.1%) neonates ≥34 weeks’ GA received antibiotics within the first 12 h of life. According to EOS calculator 55/265 (20.7%) patients would have received antibiotics with EOS incidence 2/1000 live births (p < 0.0001). Conclusion Our evidence-based protocol entails a further decrease of antibiotic overtreatment compared to EOS calculator. No negative consequences for patients were observed.
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Affiliation(s)
- Gianluigi Laccetta
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Maternal and Child Health, Santa Chiara Hospital, University of Pisa, Pisa, Italy.
| | - Massimiliano Ciantelli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Maternal and Child Health, Santa Chiara Hospital, University of Pisa, Pisa, Italy.,Centro di Formazione e Simulazione Neonatale "NINA", Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Cristina Tuoni
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Maternal and Child Health, Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Emilio Sigali
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Maternal and Child Health, Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, Faculty of Medicine, University of Pisa, Pisa, Italy
| | - Armando Cuttano
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Maternal and Child Health, Santa Chiara Hospital, University of Pisa, Pisa, Italy.,Centro di Formazione e Simulazione Neonatale "NINA", Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Sloane AJ, Carola DL, Lafferty MA, Edwards C, Greenspan J, Aghai ZH. Management of infants born to mothers with chorioamnionitis: A retrospective comparison of the three approaches recommended by the committee on fetus and newborn. J Neonatal Perinatal Med 2020; 14:383-390. [PMID: 33337392 DOI: 10.3233/npm-200531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Based on the most recently published recommendations from the Committee on the Fetus and Newborn (COFN), three approaches currently exist for the use of risk factors to identify infants who are at increased risk of early-onset sepsis (EOS). Categorical risk factor assessments recommend laboratory testing and empiric antibiotic therapy for all infants born to mothers with a clinical diagnosis of chorioamnionitis. Risk assessments based on clinical condition recommend frequent examinations and close vital sign monitoring for infants born to mothers with chorioamnionitis. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, multivariate risk assessments. The aim of our study was to compare the three risk stratification approaches recommended by the COFN for management of chorioamnionitis-exposed infants. METHODS Retrospective study of 1,521 infants born ≥35 weeks to mothers with chorioamnionitis. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition (CCA). RESULTS Hypothetical application of SRC and CCA resulted in 79.6% and 76.8-85.1% respectively fewer infants allocated empiric antibiotic therapy. While CCA recommended enhanced observation for all chorioamnionitis-exposed infants, SRC recommended routine care without enhanced observation in 44.3% infants. For the six infants (0.39%) with EOS, SRC and CCA recommended empiric antibiotics only for three symptomatic infants. CONCLUSION The SRC and CCA can reduce antibiotic use but potentially delay antibiotic treatment. The SRC does not recommend enhanced observation with frequent and prolonged vital signs for >44% of chorioamnionitis-exposed infants.
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Affiliation(s)
- A J Sloane
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - D L Carola
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - M A Lafferty
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - C Edwards
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - J Greenspan
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Z H Aghai
- Pediatrics/Neonatology, Thomas Jefferson University/Nemours, Philadelphia, PA, USA
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Morris R, Jones S, Banerjee S, Collinson A, Hagan H, Walsh H, Thornton G, Barnard I, Warren C, Reid J, Busfield A, Matthes J. Comparison of the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with NICE guideline CG149 in infants ≥34 weeks' gestation who developed early-onset sepsis. Arch Dis Child Fetal Neonatal Ed 2020; 105:581-586. [PMID: 32170032 DOI: 10.1136/archdischild-2019-317165] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 01/17/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with National Institute for Health and Care Excellence (NICE) guideline CG149 in infants ≥34 weeks' gestation who developed early-onset sepsis (EOS). DESIGN Retrospective multicentre study. SETTING Five maternity services in South West of England and Wales. PATIENTS 70 infants with EOS (<72 hours) confirmed on blood or cerebrospinal fluid culture. METHODS Retrospective virtual application of NICE and SRC through review of maternal and neonatal notes. MAIN OUTCOME MEASURE The number of infants recommended antibiotics by 4 hours of birth. RESULTS The incidence of EOS ≥34 weeks was 0.5/1000 live births. Within 4 hours of birth, antibiotics were recommended for 39 infants (55.7%) with NICE, compared with 27 (38.6%) with SRC. The 12 infants advised early treatment by NICE but not SRC remained well, only one showing transient mild symptoms after 4 hours. Another four babies received antibiotics by 4 hours outside NICE and SRC guidance. The remaining 27 infants (38.6%) received antibiotics when symptomatic after 4 hours. Only one infant who was unwell from birth, died. Eighty-one per cent of all EOS infants were treated for clinical reasons rather than for risk factors alone. CONCLUSION While both tools were poor in identifying EOS within 4 hours, NICE was superior to SRC in identifying asymptomatic cases. Currently, four out of five EOS have symptoms at first identification, the majority of whom present within 24 hours of birth. Antibiotic stewardship programmes using SRC should include enhanced observation for infants currently treated within NICE guidance.
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Affiliation(s)
- Rachel Morris
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
| | - Steve Jones
- Paediatrics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sujoy Banerjee
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
| | | | - Hannah Hagan
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Hannah Walsh
- Paediatrics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Graham Thornton
- Paediatrics, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Ian Barnard
- Neonatal Medicine, Glan Clwyd Hospital, Rhyl, Wales, UK
| | - Chris Warren
- Paediatrics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Jennifer Reid
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Alison Busfield
- Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Jean Matthes
- Neonatal Intensive Care, Singleton Hospital, Swansea, Wales, UK
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Technical assessment of the neonatal early-onset sepsis risk calculator. THE LANCET. INFECTIOUS DISEASES 2020; 21:e134-e140. [PMID: 33129425 DOI: 10.1016/s1473-3099(20)30490-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/23/2020] [Accepted: 04/27/2020] [Indexed: 11/23/2022]
Abstract
The use of the neonatal early-onset sepsis risk calculator, developed by Kaiser Permanente Northern California (CA, USA), is increasing for the management of late preterm and full term newborn babies at risk for early-onset sepsis. The calculator is based on a robust logistic regression model that provides quantitative individualised estimates of early-onset sepsis risk. Low sensitivity for prediction of sepsis at birth shows that standard perinatal risk factors alone are insufficient for ascertainment of neonatal early-onset sepsis. Performance is improved by the addition of physical examination findings at birth, but the sensitivity of combined findings remains limited. The present implementation of the calculator integrates risk factors and examination findings. A methodological error in adapting the regression for application in the population (rather than the development sample) and several subsequent modifications compromise the accuracy of quantitative predictions of the absolute risk of sepsis, but these factors are not expected to seriously undermine the use of the calculator for risk stratification. The calculator has served as an instrument of change away from previously recommended categorical risk ascertainment strategies, and its implementation reduces the need for diagnostic testing and empirical antibiotic treatment without apparent ill effects. However, the calculator should not be relied on to provide accurate estimates for individuals with regard to absolute risk of early-onset sepsis in newborn babies.
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Coleman C, Carola DL, Sloane AJ, Lafferty MA, Roman A, Cruz Y, Solarin K, Aghai ZH. A comparison of Triple I classification with neonatal early-onset sepsis calculator recommendations in neonates born to mothers with clinical chorioamnionitis. J Perinatol 2020; 40:1308-1314. [PMID: 32678316 DOI: 10.1038/s41372-020-0727-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the early-onset sepsis (EOS) calculator recommendations for infants born to mothers with clinical chorioamnionitis with those made by the Triple I classification. STUDY DESIGN Retrospective analysis of chorioamnionitis-exposed neonates ≥35 weeks. EOS risk was calculated with baseline risks of 0.5/1000 and 4/1000. Mothers were retrospectively categorized using the Triple I classification. Calculator recommendations were compared with the Triple I classification recommendations. RESULTS We included 687 chorioamnionitis-exposed neonates. With a baseline risk of 0.5/1000, the calculator recommended no evaluation in 68.4% of infants of mothers with confirmed Triple I. With a baseline risk of 4/1000, 62.3% of infants of mothers with confirmed Triple I and 57.1% of infants born to mothers who did not meet fever criteria would have received evaluation. CONCLUSIONS The EOS calculator with either baseline risk does not recommend evaluation in a large number of infants born to mothers with confirmed Triple I.
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Affiliation(s)
- Cassandra Coleman
- Pediatrics, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - David L Carola
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Amy J Sloane
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Margaret A Lafferty
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Amanda Roman
- Maternal Fetal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Yury Cruz
- Maternal Fetal Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kolawole Solarin
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Zubair H Aghai
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA.
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Comparison of institutional guidelines with established early onset sepsis risk calculator in reducing antibiotic use in an inner-city NICU in US. J Glob Antimicrob Resist 2020; 21:124-129. [PMID: 32234556 DOI: 10.1016/j.jgar.2020.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Early onset sepsis (EOS) incidence has decreased since national guidelines and intrapartum prophylaxis were introduced. However, there has been a rising concern in antibiotic overtreatment for suspicion of EOS. A web-based EOS calculator has recently been used to evaluate the risk in newborns ≥34 weeks. Our purpose was to compare local strategies with the EOS calculator in our setting with an EOS incidence of 2/1000 live births. METHODS A retrospective review of all newborns born ≥34 weeks from 1 January 2016 to 31 December 2017 was completed after receiving IRB approval. We applied the calculator to those eligible using an EOS incidence of 0.6/1000 and 2/1000 live births and divided the patients into four cohorts. The rate of antibiotic use was compared between local evidence-based guidelines and the EOS calculator. RESULTS Of the 1367 newborns included in the study, 679 received antibiotics. Over the 2 years, antibiotic utilization decreased by 38%. The calculator would have recommended antibiotics for 468 patients (31% decrease) for an EOS incidence of 0.6/1000, but with a 2/1000 incidence rate the calculator recommended antibiotics for 673 patients (1% decrease). CONCLUSIONS The EOS calculator has been helpful in optimizing antibiotic use, but its use may result in suboptimal treatment without the knowledge of local EOS incidence. Our local antibiotic stewardship guidelines seemed to be comparable to the EOS calculator, especially by the last 6 months of the study period.
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Pettinger KJ, Mayers K, McKechnie L, Phillips B. Sensitivity of the Kaiser Permanente early-onset sepsis calculator: A systematic review and meta-analysis. EClinicalMedicine 2020; 19:100227. [PMID: 32140666 PMCID: PMC7046522 DOI: 10.1016/j.eclinm.2019.11.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Determining which babies should receive antibiotics for potential early onset sepsis (EOS) is challenging. We performed a meta-analysis quantifying how many EOS cases might be 'missed' using the Kaiser Permanente electronic calculator, compared with National Institute for Health and Care Excellence (NICE) guidelines. METHODS A systematic literature search was carried out for studies citing the article in which the calculator was publicised. Studies were eligible if they presented data evaluating the calculator, either by retrospective case review or prospective cohort study. The primary outcome measure was numbers of culture positive EOS cases where the calculator did not recommend empirical antibiotics, but NICE guidelines would have. Data were pooled using a random effect meta-analysis. A subgroup analysis was performed using data from studies of babies exposed to chorioamnionitis. FINDINGS Eleven studies were included. There were a total of 75 EOS cases across the studies and a minimum of 14 (best case scenario), and a maximum of 22 (worst case scenario) cases where use of the calculator would have resulted in delayed or missed treatment, compared to if NICE guidelines had been followed. The probability of missed/delayed treatment for an EOS case were best case 0.19 [95% confidence intervals 0.11 - 0.29], worst case 0.31 [95% CI 0.17 - 0.49]. The probability of missing cases was significantly more in babies exposed to chorioamnionitis. INTERPRETATION A large proportion of EOS cases were 'missed' by the calculator. Further evaluation of the calculator is recommended before it is introduced into UK clinical practice. FUNDING None.
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Affiliation(s)
| | - Katie Mayers
- Leeds Centre for Newborn Care, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK
| | - Liz McKechnie
- Leeds Centre for Newborn Care, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington YO10 5DD, UK
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Implementation of the Neonatal Sepsis Calculator in Early-Onset Sepsis and Maternal Chorioamnionitis. Adv Neonatal Care 2020; 20:25-32. [PMID: 31569094 DOI: 10.1097/anc.0000000000000668] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Utilization of the neonatal sepsis calculator published by Kaiser Permanente is rapidly increasing. This freely available online tool can be used in assessment of early-onset sepsis (EOS) in newborns 34 weeks' gestation or more based on maternal risk factors and neonatal examination. However, many hospitals lack standard guidelines for its use, leading to provider discomfort with practice change. PURPOSE The goal of this project was to study the antibiotic use rate for EOS at a level III neonatal intensive care unit and create standardized guidelines and staff education for using the sepsis calculator. Our ultimate goal was to decrease antibiotic use for EOS in newborns 34 weeks' gestation or more. METHODS A standard quality improvement Plan-Do-Study-Act (PDSA) model was utilized with a plan to study the problem, implement the intervention, and test again for improvement. The primary outcome of interest was a decrease in the use of antibiotics for EOS in neonates 34 weeks' gestation or more. RESULTS Over a 4-month period, prior to sepsis calculator implementation, antibiotic use for suspected EOS was 11% and blood culture was done on 14.8% of live births. After implementation of the sepsis calculator and completion of the PDSA cycle, sepsis calculator use was greater than 95%, antibiotic use dropped significantly to 5% (P = .00069), and blood culture use dropped to 7.6% (P = .00046). IMPLICATIONS FOR PRACTICE Staff education and systematic intervention using a PDSA model can significantly impact patient care, decreasing the administration of antibiotics to infants at risk for sepsis. IMPLICATIONS FOR RESEARCH Future research is needed to decrease antibiotic use in premature infants less than 34 weeks' gestation with similar risk factors and clinical features.Video Abstract available at https://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=34&autoPlay=true.
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Perez EM, Taylor M, Swanson K, Laferney JD. Implementation of an antibiotic stewardship quality improvement initiative in a community hospital for infants born at ≥35 weeks. Proc (Bayl Univ Med Cent) 2019; 33:188-190. [PMID: 32313458 DOI: 10.1080/08998280.2019.1700725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 11/12/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022] Open
Abstract
We present our experience in the implementation of an antibiotic stewardship quality improvement initiative directed toward infants born at ≥35 weeks using as a primary tool the Kaiser Permanente early onset sepsis calculator (KP-EOS-C) at the Baylor Scott & White Medical Center - Frisco. After the approval and support of the medical staff and administration, we proceeded to launch an extensive educational program for all women's services nursing staff on how to utilize this calculator to communicate results to the pediatricians on staff. After implementation, we saw a 54% reduction in the number of infants undergoing sepsis workup evaluations and a 51% reduction in the number of infants receiving antibiotics (P < 0.001). We conclude that the implementation of this type of initiative may be feasible and worthwhile in other similar community hospitals, provided there is buy-in by physicians and administration as well as an extensive educational program to the hospital medical and nursing staff.
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Affiliation(s)
- Eduardo M Perez
- Division of Neonatology, Department of Pediatrics, Baylor Scott White Medical Center - FriscoFriscoTexas.,Pediatrix Medical Group of TexasDallasTexas
| | - Molly Taylor
- Division of Neonatology, Department of Pediatrics, Baylor Scott White Medical Center - FriscoFriscoTexas
| | - Kristin Swanson
- Division of Neonatology, Department of Pediatrics, Baylor Scott White Medical Center - FriscoFriscoTexas
| | - Jimmy D Laferney
- Department of Anesthesiology, Baylor Scott & White Medical Center - FriscoFriscoTexas
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Dumpa V, Avulakunta I, Shelton J, Yu T, Lakshminrusimha S. Induction of labor and early-onset Sepsis guidelines: impact on NICU admissions in Erie County, NY. Matern Health Neonatol Perinatol 2019; 5:19. [PMID: 31844538 PMCID: PMC6894216 DOI: 10.1186/s40748-019-0114-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/21/2019] [Indexed: 11/21/2022] Open
Abstract
Background Elective delivery prior to term gestation is associated with adverse neonatal outcomes. The impact of American College of Obstetricians and Gynecologists (ACOG) guidelines recommending against induction of labor (IOL) < 39 weeks’ postmenstrual age (PMA) on the frequency of early-term births and NICU admissions in Erie County, NY was evaluated in this study. Methods This is a population-based retrospective comparison of all live births and NICU admissions in Erie County, NY between pre-and post-ACOG IOL guideline epochs (2005–2008 vs. 2011–2014). Information on early-term, full/late/post-term births and NICU admissions was obtained. A detailed chart analysis of indications for admission to the Regional Perinatal Center was performed. Results During the 2005–2008 epoch, early-term births constituted 27% (11,968/44,617) of live births. The NICU admission rate was higher for early-term births (1134/11968 = 9.5%) compared to full/late/post-term (1493/27541 = 5.4%). In the 2011–2014 epoch, early-term births decreased to 23% (10,286/44,575) of live births. However, NICU admissions for early-term (1072/10286 = 10.4%) and full/late/post-term births (1892/29508 = 6.4%) did not decrease partly due to asymptomatic infants exposed to maternal chorioamnionitis admitted for empiric antibiotic therapy as per revised early-onset sepsis guidelines. Conclusions ACOG recommendations against elective IOL or cesarean delivery < 39 weeks PMA were rapidly translated to clinical practice and decreased early-term births in Erie County, NY. This decrease did not translate to reduced NICU admissions partly due to increased NICU admissions for empiric antibiotic therapy.
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Achten NB, Klingenberg C, Benitz WE, Stocker M, Schlapbach LJ, Giannoni E, Bokelaar R, Driessen GJA, Brodin P, Uthaya S, van Rossum AMC, Plötz FB. Association of Use of the Neonatal Early-Onset Sepsis Calculator With Reduction in Antibiotic Therapy and Safety: A Systematic Review and Meta-analysis. JAMA Pediatr 2019; 173:1032-1040. [PMID: 31479103 PMCID: PMC6724419 DOI: 10.1001/jamapediatrics.2019.2825] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE The neonatal early-onset sepsis (EOS) calculator is a clinical risk stratification tool increasingly used to guide the use of empirical antibiotics for newborns. Evidence on the effectiveness and safety of the EOS calculator is essential to inform clinicians considering implementation. OBJECTIVE To assess the association between management of neonatal EOS guided by the neonatal EOS calculator (compared with conventional management strategies) and reduction in antibiotic therapy for newborns. DATA SOURCES Electronic searches in MEDLINE, Embase, Web of Science, and Google Scholar were conducted from 2011 (introduction of the EOS calculator model) through January 31, 2019. STUDY SELECTION All studies with original data that compared management guided by the EOS calculator with conventional management strategies for allocating antibiotic therapy to newborns suspected to have EOS were included. DATA EXTRACTION AND SYNTHESIS Following PRISMA-P guidelines, relevant data were extracted from full-text articles and supplements. CHARMS (Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) tools were used to assess the risk of bias and quality of evidence. Meta-analysis using a random-effects model was conducted for studies with separate cohorts for EOS calculator and conventional management strategies. MAIN OUTCOMES AND MEASURES The difference in percentage of newborns treated with empirical antibiotics for suspected or proven EOS between management guided by the EOS calculator and conventional management strategies. Safety-related outcomes involved missed cases of EOS, readmissions, treatment delay, morbidity, and mortality. RESULTS Thirteen relevant studies analyzing a total of 175 752 newborns were included. All studies found a substantially lower relative risk (range, 3%-60%) for empirical antibiotic therapy, favoring the EOS calculator. Meta-analysis revealed a relative risk of antibiotic use of 56% (95% CI, 53%-59%) in before-after studies including newborns regardless of exposure to chorioamnionitis. Evidence on safety was limited, but proportions of missed cases of EOS were comparable between management guided by the EOS calculator (5 of 18 [28%]) and conventional management strategies (8 of 28 [29%]) (pooled odds ratio, 0.96; 95% CI, 0.26-3.52; P = .95). CONCLUSIONS AND RELEVANCE Use of the neonatal EOS calculator is associated with a substantial reduction in the use of empirical antibiotics for suspected EOS. Available evidence regarding safety of the use of the EOS calculator is limited, but shows no indication of inferiority compared with conventional management strategies.
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Affiliation(s)
- Niek B. Achten
- Department of Pediatrics, Tergooi Hospital, Blaricum, the Netherlands,Faculty of Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Claus Klingenberg
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway,Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | | | - Martin Stocker
- Department of Pediatrics, Children’s Hospital Lucerne, Lucerne, Switzerland
| | - Luregn J. Schlapbach
- Paediatric Critical Care Research Group, Child Health Research Centre, University of Queensland, Brisbane, Australia,Paediatric Intensive Care Unit, Queensland Children’s Hospital, Brisbane, Australia,Department of Pediatrics, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eric Giannoni
- Department Woman-Mother-Child, Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - Robin Bokelaar
- Department of Pediatrics, Tergooi Hospital, Blaricum, the Netherlands
| | - Gertjan J. A. Driessen
- Department of Pediatrics, Juliana Children’s Hospital, Haga Teaching Hospital, The Hague, the Netherlands
| | - Petter Brodin
- Science for Life Laboratory, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Sabita Uthaya
- Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Annemarie M. C. van Rossum
- Department of Pediatrics, Erasmus University Medical Centre-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Frans B. Plötz
- Department of Pediatrics, Tergooi Hospital, Blaricum, the Netherlands
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An Institutional Approach to the Management of Asymptomatic Chorioamnionitis-Exposed Infants Born ≥35 Weeks Gestation. Pediatr Qual Saf 2019; 4:e238. [PMID: 32010864 PMCID: PMC6946240 DOI: 10.1097/pq9.0000000000000238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/22/2019] [Indexed: 01/15/2023] Open
Abstract
Supplemental Digital Content is available in the text. Our newborn practice routinely treated asymptomatic chorioamnionitis-exposed infants born at 35 weeks gestation or greater with empiric antibiotics. Starting April 1, 2017, we implemented an algorithm of not treating, unless there was an abnormal clinical and/or laboratory evaluation. The goal of this quality improvement initiative was to reduce the percentage of chorioamnionitis-exposed infants treated with antibiotics (primary outcome measure) to <50%.
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Sloane AJ, Coleman C, Carola DL, Lafferty MA, Edwards C, Greenspan J, Aghai ZH. Use of a Modified Early-Onset Sepsis Risk Calculator for Neonates Exposed to Chorioamnionitis. J Pediatr 2019; 213:52-57. [PMID: 31208783 DOI: 10.1016/j.jpeds.2019.04.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/19/2019] [Accepted: 04/30/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To validate the recently modified Kaiser Permanente early-onset sepsis (EOS) calculator with a higher baseline incidence in chorioamnionitis exposed neonates. STUDY DESIGN This is a retrospective study of chorioamnionitis-exposed neonates born at ≥35 weeks of gestation with a known EOS incidence of 4.3/1000. The risk and management categories were calculated using the calculator with an incidence of 4/1000. The results were compared with a previous analysis of the same cohort that used an EOS incidence of 0.5/1000. RESULTS In our sample, the EOS calculator recommends at least a blood culture in 834 of 896 (93.1%) and empiric antibiotics in 533 of 896 (59.5%) chorioamnionitis-exposed neonates when using an EOS incidence of 4/1000. This captures 5 of 5 neonates (100%) with EOS. When using a baseline EOS incidence of 0.5/1000, the calculator recommends at least a blood culture in only 289 of 896 (32.2%) and empiric antibiotics in only 209 of 896 (23.3%) neonates, but fails to recommend empiric antibiotics in 2 of 5 neonates with EOS (40%). CONCLUSIONS When using an EOS risk of 4 of 1000 in infants exposed to mothers with chorioamnionitis, the EOS calculator has the ability to capture an increased number of neonates with culture-positive EOS. However, this change also leads to nearly a 3-fold increase in the use of empiric antibiotics and an evaluation with blood culture in almost all infants born to mothers with chorioamnionitis.
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Affiliation(s)
- Amy J Sloane
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - Cassandra Coleman
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - David L Carola
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - Margaret A Lafferty
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - Caroline Edwards
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - Jay Greenspan
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA
| | - Zubair H Aghai
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, PA.
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32
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Hershkovich-Shporen C, Ujirauli N, Oren S, Juster Reicher ADA, Gadassi N, Guri A, Flidel-Rimon O. Not all newborns born to mothers with clinical chorioamnionitis need to be treated. J Matern Fetal Neonatal Med 2019; 34:1949-1954. [DOI: 10.1080/14767058.2019.1651281] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Neli Ujirauli
- Department of Pediatrics, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
| | - Shachar Oren
- Department of Pediatrics, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
| | - ADA Juster Reicher
- Department of Neonatology, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
| | - Noa Gadassi
- Department of Neonatology, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
| | - Alex Guri
- Department of Pediatrics, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
| | - Orna Flidel-Rimon
- Department of Neonatology, Kaplan Medical Center, Hebrew University of Jerusalem, Rehovot, Israel
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33
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Sahni M, Franco-Fuenmayor ME, Shattuck K. Management of Late Preterm and Term Neonates exposed to maternal Chorioamnionitis. BMC Pediatr 2019; 19:282. [PMID: 31409304 PMCID: PMC6693155 DOI: 10.1186/s12887-019-1650-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background Chorioamnionitis is a significant risk factor for early-onset neonatal sepsis. However, empiric antibiotic treatment is unnecessary for most asymptomatic newborns exposed to maternal chorioamnionitis (MC). The purpose of this study is to report the outcomes of asymptomatic neonates ≥35 weeks gestational age (GA) exposed to MC, who were managed without routine antibiotic administration and were clinically monitored while following complete blood cell counts (CBCs). Methods A retrospective chart review was performed on neonates with GA ≥ 35 weeks with MC during calendar year 2013. IT ratio (immature: total neutrophils) was considered suspicious if ≥0.3. The data were analyzed using independent sample T-tests. Results Among the 275 neonates with MC, 36 received antibiotics for possible sepsis. Twenty-one were treated with antibiotics for > 48 h for clinical signs of infection; only one infant had a positive blood culture. All 21 became symptomatic prior to initiating antibiotics. Six showed worsening of IT ratio. Thus empiric antibiotic administration was safely avoided in 87% of neonates with MC. 81.5% of the neonates had follow-up appointments within a few days and at two weeks of age within the hospital system. There were no readmissions for suspected sepsis. Conclusions In our patient population, using CBC indices and clinical observation to predict sepsis in neonates with MC appears safe and avoids the unnecessary use of antibiotics.
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Affiliation(s)
- Mitali Sahni
- Division of Neonatology, Drexel University College of Medicine, Philadelphia, PA, USA. .,St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA.
| | | | - Karen Shattuck
- Division of Neonatology, Department of Pediatrics, University of Texas Medical Branch, Galveston, TX, USA
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34
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Gluck K. New Approaches to the Evaluation and Management of Well-Appearing Term and Late Preterm Neonates at Risk for Early-Onset Sepsis. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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35
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Bridges M, Pesek E, McRae M, Chabra S. Use of an Early Onset-Sepsis Calculator to Decrease Unnecessary NICU Admissions and Increase Exclusive Breastfeeding. J Obstet Gynecol Neonatal Nurs 2019; 48:372-382. [DOI: 10.1016/j.jogn.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2019] [Indexed: 10/27/2022] Open
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Sharma V, Adkisson C, Gupta K. Managing Infants Exposed to Maternal Chorioamnionitis by the Use of Early-Onset Sepsis Calculator. Glob Pediatr Health 2019; 6:2333794X19833711. [PMID: 31008151 PMCID: PMC6457026 DOI: 10.1177/2333794x19833711] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/13/2018] [Accepted: 02/01/2019] [Indexed: 12/27/2022] Open
Abstract
Objective. To reduce neonatal intensive care unit admission rate
(NAR) and antibiotic utilization rate (AUR) in ≥36 weeks gestational age infants
exposed to maternal chorioamnionitis (MC) through the application of early-onset
sepsis calculator (EOSCAL). Study Design. This is a
single-center cohort study. All infants born ≥36 weeks gestational age and
exposed to MC were compared for NAR, AUR, and laboratory evaluation rate (LER) 2
years after and 1 year before the implementation of EOSCAL.
Results. There is a significant decrease in NAR
(P < .001), AUR (P < .04), and LER
for blood culture, complete blood count, and C-reactive protein
(P < .001) after implementation of EOSCAL. If infants
received antibiotics, it was for significantly less number of doses
(P < .01). There was no increase in the readmission
rate. Conclusion. Use of EOSCAL significantly decreases the
rate of NAR, AUR, and LER in infants exposed to MC, without affecting
readmission rates and late antibiotic use.
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Affiliation(s)
- Vinay Sharma
- Hennepin County Medical Center, Minneapolis, MN, USA
| | | | - Kunal Gupta
- Hennepin County Medical Center, Minneapolis, MN, USA
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Gong CL, Dasgupta-Tsinikas S, Zangwill KM, Bolaris M, Hay JW. Early onset sepsis calculator-based management of newborns exposed to maternal intrapartum fever: a cost benefit analysis. J Perinatol 2019; 39:571-580. [PMID: 30692615 DOI: 10.1038/s41372-019-0316-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/05/2018] [Accepted: 12/27/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine potential net monetary benefit of an early onset sepsis calculator-based approach for management of neonates exposed to maternal intrapartum fever, compared to existing guidelines. STUDY DESIGN We performed a cost-benefit analysis comparing two management approaches for newborns >34 weeks gestational age exposed to maternal intrapartum fever. Probabilities of sepsis and meningitis, consequences of infection and antibiotic use, direct medical costs, and indirect costs for long-term disability and mortality were considered. RESULTS A calculator-based approach resulted in a net monetary benefit of $3998 per infant with a 60% likelihood of net benefit in probabilistic sensitivity analysis. Our model predicted a 67% decrease in antibiotic use in the calculator arm. The absolute difference for all adverse clinical outcomes between approaches was ≤0.6%. CONCLUSIONS Compared to existing guidelines, a calculator-based approach for newborns exposed to maternal intrapartum fever yields a robust net monetary benefit, largely by preventing unnecessary antibiotic treatment.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA. .,Children's Hospital of Los Angeles, Fetal & Neonatal Institute, Los Angeles, CA, USA.
| | - Shom Dasgupta-Tsinikas
- Division of Pediatric Infectious Diseases, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Kenneth M Zangwill
- Division of Pediatric Infectious Diseases, Harbor-UCLA Medical Center, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Michael Bolaris
- Division of Pediatric Infectious Diseases, Harbor-UCLA Medical Center, Los Angeles, CA, USA.,Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
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Carracedo-Martinez E, Gonzalez-Gonzalez C, Teixeira-Rodrigues A, Prego-Dominguez J, Takkouche B, Herdeiro MT, Figueiras A. Computerized Clinical Decision Support Systems and Antibiotic Prescribing: A Systematic Review and Meta-analysis. Clin Ther 2019; 41:552-581. [PMID: 30826093 DOI: 10.1016/j.clinthera.2019.01.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to perform a systematic review and meta-analysis of studies performed in primary care centers and hospital facilities that evaluated the effectiveness of computerized clinical decision support systems (CDSSs) in decision making on the prescription of any given antibiotic. METHODS We conducted a search of the MEDLINE and EMBASE databases. A meta-analysis was then conducted of all variables with results reported in >2 studies. FINDINGS A total of 42 of the 46 studies included in the review identified a statistically significant advantage for CDSSs in ≥1 study variables. The effect of CDSSs on the percentage accuracy of the antibiotic spectrum prescribed empirically with respect to the microbial agent's susceptibility, which is one of the most frequently studied outcome variables, was examined in 7 studies, all undertaken in hospital settings. In all these studies but one, CDSSs resulted in a statistically significant increase in percentage accuracy. The other study variables present in >2 studies had more inconsistent results. Although the results of the meta-analysis of the variables percentage accuracy, antibiotic prescription rate in hospital, percentage adherence to antibiotic prescription guidelines in primary care or hospital, and percentage of inappropriate prescriptions for antibiotics in primary care were statistically significantly favorable to CDSSs; in the case of hospital length of stay and mortality, they were favorable although not statistically significantly. IMPLICATIONS CDSSs appear to be useful for variables such as the percentage of appropriate empirical treatment in the hospital setting or to induce changes in antibiotics prescription rate. Even so, more better quality studies are required to draw clearer conclusions in respect of morbidity and mortality outcome variables and other settings.
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Affiliation(s)
- Eduardo Carracedo-Martinez
- Santiago de Compostela Health Area, Galician Health Service (Servizo Galego de Saúde-SERGAS), Spanish National Health System, Santiago de Compostela, Spain.
| | - Christian Gonzalez-Gonzalez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Teixeira-Rodrigues
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Jesus Prego-Dominguez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences and Institute for Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Santiago de Compostela, Spain; Institute of Health Research of Santiago de Compsotela (IDIS), Spain
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Abstract
Neonatal early-onset sepsis is a serious health concern for term and late preterm infants. Screening for early-onset sepsis is often challenging due to variation in practice, nonspecific laboratory markers, and clinical findings that mimic immaturity. This systematic review evaluates the evidence for the effectiveness of the Neonatal Early-Onset Sepsis Calculator (EOScalc) as a screening tool to appropriately identify neonatal early-onset sepsis and the ability to decrease unnecessary antibiotic use in late preterm and term infants. A comprehensive search of retrospective cohort and retrospective case-control studies was conducted using 5 databases. Studies were included if they evaluated the EOScalc within the defined parameters of use and excluded if they were not published. Six studies were identified and included from 2014 to 2017. Study comparisons varied on the basis of differing clinical practice and use of the EOScalc. Findings included in this review suggest that utilization of the EOScalc can reduce empiric antibiotic therapy, unnecessary laboratory testing, and separation of infants and mothers without increasing infant mortality.
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40
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Affiliation(s)
- David Carola
- Pediatrics Sidney Kimmel Medical School Thomas Jefferson University/Nemours Philadelphia, Pennsylvania
| | - Jay Greenspan
- Pediatrics Sidney Kimmel Medical School Thomas Jefferson University/Nemours Philadelphia, Pennsylvania
| | - Zubair H Aghai
- Pediatrics Sidney Kimmel Medical School Thomas Jefferson University/Nemours Philadelphia, Pennsylvania
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41
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Gievers LL, Sedler J, Phillipi CA, Dukhovny D, Geddes J, Graven P, Chan B, Khaki S. Implementation of the sepsis risk score for chorioamnionitis-exposed newborns. J Perinatol 2018; 38:1581-1587. [PMID: 30158677 DOI: 10.1038/s41372-018-0207-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND To prevent early onset sepsis (EOS), ~10% of neonates receive antibiotics based on CDC recommendations regarding chorioamnionitis exposure. A sepsis risk score (SRS) predicts EOS and spares unnecessary evaluation and treatment. LOCAL PROBLEM Chorioamnionitis-exposed neonates utilize significant resources. METHODS An SRS algorithm was implemented to decrease resource utilization in chorioamnionitis-exposed neonates ≥35 weeks'. Outcome measures included antibiotic exposure, time in NICU, laboratory evaluations, and length of stay (LOS). Balancing measures were missed cases of EOS and readmissions. Data were assessed using run charts. INTERVENTIONS Plan-Do-Study-Act cycles were utilized to process map, implement and reinforce the algorithm. RESULTS A number of 356 patients met inclusion criteria. After algorithm implementation, antibiotic exposure reduced from 95 to 9%, laboratory evaluation from 96 to 22%, NICU observation from 73 to 10%. LOS remained unchanged. No missed cases of EOS, nor sepsis readmissions. CONCLUSIONS Algorithm implementation decreased antibiotic and resource utilization without missing cases of EOS.
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Affiliation(s)
- Ladawna L Gievers
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA.
| | | | - Carrie A Phillipi
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Jonah Geddes
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, USA
| | - Peter Graven
- Center for Health Systems Effectiveness, Oregon Health and Science University, Portland, OR, USA
| | - Benjamin Chan
- School of Public Health, Oregon Health and Science University, Portland, OR, USA
| | - Sheevaun Khaki
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
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Azuma D, Boulais J. Does maternal chorioamnionitis have to equal antibiotics in an asymptomatic infant? J Perinatol 2018; 38:778-780. [PMID: 29887607 DOI: 10.1038/s41372-018-0141-8] [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: 04/30/2018] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Dara Azuma
- Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA.
| | - Jaclyn Boulais
- Division of Newborn Medicine, Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA.,Tufts Medical School, Boston, MA, USA
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Is early-onset sepsis risk calculator safe for the management of neonates born to mothers with chorioamnionitis? J Perinatol 2018; 38:769-770. [PMID: 29467522 DOI: 10.1038/s41372-018-0069-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/11/2018] [Indexed: 11/08/2022]
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Achten NB, Dorigo-Zetsma JW, van der Linden PD, van Brakel M, Plötz FB. Sepsis calculator implementation reduces empiric antibiotics for suspected early-onset sepsis. Eur J Pediatr 2018; 177:741-746. [PMID: 29455368 DOI: 10.1007/s00431-018-3113-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/07/2018] [Indexed: 12/22/2022]
Abstract
UNLABELLED Significant overtreatment with antibiotics for suspected early onset sepsis (EOS) constitutes a persisting clinical problem, generating unnecessary risks, harms, and costs for many newborns. We aimed to study feasibility and impact of a sepsis calculator to help guide antibiotic for suspected EOS in a European setting. In this single-center study, the sepsis calculator was implemented as an addition to and in accordance with existing protocols. One thousand eight hundred seventy-seven newborns ≥ 35 weeks of gestational age were prospectively evaluated; an analogous retrospective control group (n = 2076) was used for impact analysis. We found that empirical treatment with intravenous antibiotics for suspected EOS was reduced from 4.8 to 2.7% after sepsis calculator implementation (relative risk reduction 44% (95% confidence interval 21.4-59.5%)). No evidence for changes in time to treatment start, treatment duration, or proven sepsis rates was found. Adherence to sepsis calculator recommendation was 91%. CONCLUSION Pragmatic and feasible implementation of the sepsis calculator yields a 44% reduction of empirical use of antibiotics for EOS, without signs of delay or prolongation of treatment. These findings warrant a multicenter, nation-wide, randomized study evaluating systematic use of the sepsis calculator prediction model and its effects in clinical practice outside of the USA. What is known: • Significant overtreatment with antibiotics for suspected early-onset sepsis results in unnecessary costs, risks, and harms. • Implementation of the sepsis calculator in the USA has resulted in a significant decrease in empirical antibiotic treatment, without apparent adverse events. What is new: • Implementation of the sepsis calculator in daily clinical decision-making in a Dutch teaching hospital is feasible in conjunction with existing protocols, with high adherence. • Antibiotic therapy for suspected early-onset sepsis was reduced by 44% following implementation of the calculator.
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Affiliation(s)
- Niek B Achten
- Department of Paediatrics, Tergooi hospitals, Rijksstraatweg 1, 1261 AN, Blaricum, The Netherlands.
| | | | | | - Monique van Brakel
- Department of Paediatrics, Tergooi hospitals, Rijksstraatweg 1, 1261 AN, Blaricum, The Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooi hospitals, Rijksstraatweg 1, 1261 AN, Blaricum, The Netherlands
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Paul SP, Richardson K. There is an urgent need for evidence-based internationally agreed guidelines for the assessment of neonates at risk of developing early-onset sepsis. Evid Based Nurs 2018; 21:46. [PMID: 29459384 DOI: 10.1136/eb-2017-102770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 11/04/2022]
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