Is early-onset sepsis risk calculator safe for the management of neonates born to mothers with chorioamnionitis?

Kaiser Permanente early-onset sepsis calculator as a safe tool for reducing antibiotic use among chorioamnionitis-exposed term neonates: Qatar experience

Being an important cause of early-onset neonatal sepsis, clinical chorioamnionitis in the mother results in frequent laboratory workup and antibiotic use for the neonate. Neonatal intensive care units (NICUs) in Qatar follow the categorical approach recommended by the Centers for Disease Control and Prevention, USA, and all chorioamnionitis-exposed neonates receive antibiotics.Our project aimed to reduce antibiotic use among chorioamnionitis-exposed, asymptomatic term babies by adopting the early-onset sepsis calculator (EOSCAL). Reduction of blood culture and NICU stay duration were added as secondary objectives later.The Institute of Healthcare Improvement Model of Improvement was used. Antibiotic use rate was the primary outcome measure. Blood culture rate and early transfer to the postnatal ward were added after 1 year. The process measures included the EOSCAL use rate and calculation error rate. The rate of positive culture among untreated babies within the first week was taken as a balancing measure. Monthly data were collected from February 2020 and entered as run charts. Calculation errors were dealt by multiple PDSAs. Additional outcome measures were added in January 2021. Data collection and monitoring continued till December 2022.Among 3837 inborn NICU admissions, 464 (12 %) were chorioamnionitis-exposed babies. Of them, 341 (74%) cases were eligible for inclusion. Among eligible cases, 270 (79%) did not receive antibiotics. Blood culture could be avoided among 106 (97% of low-risk babies) and NICU stay was reduced among 45 (92% of eligible low-risk babies). None of the untreated babies developed sepsis during the first week.Implementation of this project effectively and safely reduced the antibiotic use and blood culture rate among term, well-appearing babies exposed to chorioamnionitis. The project resulted in enhanced patient safety, experience and flow and reduced cost. It is recommendable to other NICU settings in Qatar.

Stratification of Culture-Proven Early-Onset Sepsis Cases by the Neonatal Early-Onset Sepsis Calculator: An Individual Patient Data Meta-Analysis

OBJECTIVES

To provide a comprehensive assessment of case stratification by the Neonatal Early-Onset Sepsis (EOS) Calculator, a novel tool for reducing unnecessary antibiotic treatment.

STUDY DESIGN

A systematic review with individual patient data meta-analysis was conducted, extending PROSPERO record CRD42018116188. Cochrane, PubMed/MEDLINE, EMBASE, Web of Science, Google Scholar, and major conference proceedings were searched from 2011 through May 1, 2020. Original data studies including culture-proven EOS case(s) with EOS Calculator application, independent from EOS Calculator development, and including representative birth cohorts were included. Relevant (individual patient) data were extracted from full-text and data queries. The main outcomes were the proportions of EOS cases assigned to risk categories by the EOS Calculator at initial assessment and within 12 hours. Evidence quality was assessed using Newcastle-Ottawa scale, Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies, and GRADE tools.

RESULTS

Among 543 unique search results, 18 were included, totaling more than 459 000 newborns. Among 234 EOS cases, EOS Calculator application resulted in initial assignments to (strong consideration of) empiric antibiotic administration for 95 (40.6%; 95% CI, 34.2%-47.2%), more frequent vital signs for 36 (15.4%; 95% CI, 11.0%-20.7%), and routine care for 103 (44.0%; 95% CI, 37.6%-50.6%). By 12 hours of age, these proportions changed to 143 (61.1%; 95% CI, 54.5%-67.4%), 26 (11.1%; 95% CI, 7.4%-15.9%), and 65 (27.8%; 95% CI, 22.1%-34.0%) of 234 EOS cases, respectively.

CONCLUSIONS

EOS Calculator application assigns frequent vital signs or routine care to a substantial proportion of EOS cases. Clinical vigilance remains essential for all newborns.

Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience

BACKGROUND

Neonatal antibiotic use is associated with a greater risk of nosocomial infection, necrotizing enterocolitis, and mortality. It can induce drug-resistant pathogens that contribute to increased neonatal morbidity/mortality, healthcare costs, and length of stay. Prior to the antibiotic stewardship program, decisions to obtain blood cultures and empiric antibiotics for possible Early-onset Sepsis (EOS) in late preterm and term infants upon NICU admission were provider-dependent rather than algorithm-based. We aimed to decrease empiric antibiotic prescription from 70% to 56% (20% decrease) in infants ≥34 weeks gestation admitted to the NICU.

METHODS

The stewardship initiative comprised the following practice changes: (1) use of the Neonatal Sepsis Risk Calculator (SRC); and (2) a 36-hour time-out for prescribed empiric antibiotics. Data was retrospectively collected and analyzed for inborn infants pre-intervention (January 2015-December 2015; n = 263) and post-intervention (August 2016-September 2017; n = 279). Data regarding compliance with the new antibiotic guideline were collected and disseminated to the team every week. Overlap between CDC guidelines and calculator recommendations were studied.

RESULTS

Pre-and post-intervention outcomes were analyzed using chi-square tests. There was a significant post-intervention reduction in the rate of both antibiotic prescriptions (29.4% decline; 70.3% vs. 49.6%; p < 0.001) and sepsis evaluations (24.3% decline; 90.9% vs. 68.8%; p < 0.001). No difference (p = 0.271) in culture-positive EOS cases was observed. There was 92% overlap in blood culture recommendations and 95% overlap between antibiotic recommendations when current CDC guidelines were compared to the SRC.

CONCLUSION

A significant reduction in antibiotic use and sepsis evaluations was achieved for late preterm and term infants upon NICU admission. No clinical deterioration occurred in post-intervention infants who did not receive antibiotics. There is significant overlap between CDC guidelines and SRC recommendations.

An Institutional Approach to the Management of Asymptomatic Chorioamnionitis-Exposed Infants Born ≥35 Weeks Gestation

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%.

Sepsis calculator for neonatal early onset sepsis - a systematic review and meta-analysis

BACKGROUND

Over investigation and overuse of empirical antibiotics is a concern in management of neonatal early onset sepsis (EOS) using the Centers for Disease Control and Prevention guidelines. "Sepsis calculator" is a risk-based prediction model for managing neonates at risk of EOS.

OBJECTIVE

To compare outcomes of neonatal EOS using of sepsis calculator versus conventional approach.

METHODS

A systematic review of randomized controlled trials (RCT) and non-RCTs reporting on outcomes after implementation of sepsis calculator for EOS for neonates >34-week gestation was conducted using the Cochrane methodology. Databases PubMed, CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May 2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS. Secondary outcomes included hospital admissions and readmissions, blood culture positive EOS and mortality. The level of evidence (LOE) was summarized using the GRADE guidelines.

RESULTS

A total of 387 articles were retrieved after initial search. Six high quality non-RCTs fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22 (0.14-0.36); p < .00001; heterogeneity (I²) = 97%, Number needed to treat (NNT): 22], laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I² = 99%, NNT = 8], and admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I² = 98%, NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and readmissions.

CONCLUSION

Moderate quality evidence indicates that the implementation of a sepsis calculator was associated with reduced usage of antibiotics, laboratory tests and admission to neonatal unit with no increase in mortality and readmissions.