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Stocker M, Rosa-Mangeret F, Agyeman PKA, McDougall J, Berger C, Giannoni E. Management of neonates at risk of early onset sepsis: a probability-based approach and recent literature appraisal : Update of the Swiss national guideline of the Swiss Society of Neonatology and the Pediatric Infectious Disease Group Switzerland. Eur J Pediatr 2024:10.1007/s00431-024-05811-0. [PMID: 39417838 DOI: 10.1007/s00431-024-05811-0] [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: 08/11/2024] [Revised: 09/26/2024] [Accepted: 10/03/2024] [Indexed: 10/19/2024]
Abstract
In Switzerland and other high-income countries, one out of 3000 to 5000 term and late preterm neonates develops early onset sepsis (EOS) associated with a mortality of around 3%, while incidence and mortality of EOS in very preterm infants are substantially higher. Exposure to antibiotics for suspected EOS is disproportionally high compared to the incidence of EOS with consequences for future health and antimicrobial resistance (AMR). A safe reduction of unnecessary antibiotic treatment has to be a major goal of new management strategies and guidelines. Antibiotics should be administered immediately in situations with clinical signs of septic shock. Group B streptococcus (GBS) and Escherichia coli (E. coli) are the leading pathogens of EOS. Amoxicillin combined with an aminoglycoside remains the first choice for empirical treatment. Serial physical examinations are recommended for all neonates with risk factors for EOS. Neonates without any clinical signs suggestive of EOS should not be treated with antibiotics. In Switzerland, we do not recommend the use of the EOS calculator, a risk stratification tool, due to its unclear impact in a population with an observed antibiotic exposure below 3%. Not all neonates with respiratory distress should be empirically treated with antibiotics. Isolated tachypnea or respiratory distress starting immediately after delivery by elective caesarean section or a clearly assessed alternative explanation than EOS for clinical signs may point towards a low probability of sepsis. On the other hand, unexplained prematurity with risk factors has an inherent higher risk of EOS. Before the start of antibiotic therapy, blood cultures should be drawn with a minimum volume of 1 ml in a single aerobic blood culture bottle. This standard procedure allows antibiotics to be stopped after 24 to 36 h if no pathogen is detected in blood cultures. Current data do not support the use of PCR-based pathogen detection in blood as a standard method. Lumbar puncture is recommended in blood culture-proven EOS, critical illness, or in the presence of neurological symptoms such as seizures or altered consciousness. The accuracy of a single biomarker measurement to distinguish inflammation from infection is low in neonates. Therefore, biomarker guidance is not a standard part of decision-making regarding the start or stop of antibiotic therapy but may be used as part of an algorithm and after appropriate education of health care teams. Every newborn started on antibiotics should be assessed for organ dysfunction with prompt initiation of respiratory and hemodynamic support if needed. An elevated lactate may be a sign of poor perfusion and requires a comprehensive assessment of the clinical condition. Interventions to restore perfusion include fluid boli with crystalloids and catecholamines. Neonates in critical condition should be cared for in a specialized unit. In situations with a low probability of EOS, antibiotics should be stopped as early as possible within the first 24 h after the start of therapy. In cases with microbiologically proven EOS, reassessment and streamlining of antibiotic therapy in neonates is an important step to minimize AMR. CONCLUSION This guideline, developed through a critical review of the literature, facilitates a probability-based approach to the management of neonates at risk of early onset sepsis. WHAT IS KNOWN • Neonatal exposure to antibiotics is disproportionally high compared with the incidence of early onset sepsis with implications for future health and antimicrobial resistance. WHAT IS NEW • A probability-based approach may facilitate a more balanced management of neonatal sepsis and antibiotic stewardship.
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Affiliation(s)
- Martin Stocker
- Clinic of Pediatric Intensive Care and Neonatology, Children's Hospital of Central Switzerland and University of Lucerne, Lucerne, Switzerland.
| | - Flavia Rosa-Mangeret
- Neonatology and Paediatric Intensive Care Unit, Geneva University Hospitals and Geneva University, Geneva, Switzerland
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jane McDougall
- Department of Neonatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Berger
- Department of Pediatrics, Children's University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Eric Giannoni
- Clinic of Neonatology, Department Mother-Woman-Child, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Mascarenhas D, Ho MSP, Ting J, Shah PS. Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis. Pediatrics 2024; 153:e2023065091. [PMID: 38766702 DOI: 10.1542/peds.2023-065091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal sepsis is a significant contributor to mortality and morbidity; however, the uncontrolled use of antimicrobials is associated with significant adverse effects. Our objective with this article is to review the components of neonatal antimicrobial stewardship programs (ASP) and their effects on clinical outcomes, cost-effectiveness, and antimicrobial resistance. METHODS We selected randomized and nonrandomized trials and observational and quality improvement studies evaluating the impact of ASP with a cutoff date of May 22, 2023. The data sources for these studies included PubMed, Medline, Embase, Cochrane CENTRAL, Web of Science, and SCOPUS. Details of the ASP components and clinical outcomes were extracted into a predefined form. RESULTS Of the 4048 studies retrieved, 70 studies (44 cohort and 26 observational studies) of >350 000 neonates met the inclusion criteria. Moderate-certainty evidence reveals a significant reduction in antimicrobial initiation in NICU (pooled risk difference [RD] 19%; 95% confidence interval [CI] 14% to 24%; 21 studies, 27 075 infants) and combined NICU and postnatal ward settings (pooled RD 8%; 95% CI 6% to 10%; 12 studies, 358 317 infants), duration of antimicrobial agents therapy (pooled RD 20%; 95% CI 10% to 30%; 9 studies, 303 604 infants), length of therapy (pooled RD 1.82 days; 95% CI 1.09 to 2.56 days; 10 studies, 157 553 infants), and use of antimicrobial agents >5 days (pooled RD 9%; 95% CI 3% to 15%; 5 studies, 9412 infants). Low-certainty evidence reveals a reduction in economic burden and drug resistance, favorable sustainability metrices, without an increase in sepsis-related mortality or the reinitiation of antimicrobial agents. Studies had heterogeneity with significant variations in ASP interventions, population settings, and outcome definitions. CONCLUSIONS Moderate- to low-certainty evidence reveals that neonatal ASP interventions are associated with reduction in the initiation and duration of antimicrobial use, without an increase in adverse events.
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Affiliation(s)
- Dwayne Mascarenhas
- Neonatal-Perinatal Medicine Fellowship Training Program, University of Toronto, Toronto, Ontario
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
| | | | - Joseph Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Prakesh S Shah
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
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Sonney KM, Tomasini D, Aden JK, Drumm CM. Utility of the Neonatal Early-Onset Sepsis Calculator in a Low-Risk Population. Am J Perinatol 2024; 41:e3164-e3169. [PMID: 37913817 PMCID: PMC11150069 DOI: 10.1055/a-2202-3830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To compare early-onset sepsis (EOS) risk estimation and recommendations for infectious evaluation and/or empiric antibiotics using a categorical risk assessment versus the Neonatal Early-Onset Sepsis Calculator in a low-risk population. STUDY DESIGN Retrospective chart review of late preterm (≥350/7-366/7 weeks' gestational age) and term infants born at the Brooke Army Medical Center between January 1, 2012 and August 29, 2019. We evaluated those born via cesarean section with rupture of membranes (ROM) < 10 minutes. Statistical analysis was performed to compare recommendations from a categorical risk assessment versus the calculator. RESULTS We identified 1,187 infants who met inclusion criteria. A blood culture was obtained within 72 hours after birth from 234 (19.7%) infants and 170 (14.3%) received antibiotics per routine clinical practice, using categorical risk assessment. Respiratory distress was the most common indication for evaluation, occurring in 173 (14.6%) of patients. After applying the Neonatal Early-Onset Sepsis Calculator to this population, the recommendation was to obtain a blood culture on 166 (14%), to start or strongly consider starting empiric antibiotics on 164 (13.8%), and no culture or antibiotics on 1,021 (86%). Utilizing calculator recommendations would have led to a reduction in frequency of blood culture (19.7 vs. 14%, p < 0.0001) but no reduction in empiric antibiotics (14.3 vs. 13.8%, p = 0.53). There were no cases of culture-proven EOS. CONCLUSION This population is low risk for development of EOS; however, 19.7% received an evaluation for infection and 14.3% received antibiotics. Utilization of the Neonatal Early-Onset Sepsis Risk Calculator would have led to a significant reduction in the evaluation for EOS but no reduction in antibiotic exposure. Consideration of delivery mode and indication for delivery may be beneficial to include in risk assessments for EOS. KEY POINTS · Cesarean section with rupture of membranes at delivery confers low risk for EOS.. · Respiratory distress often triggers an EOS evaluation.. · Delivery mode should be considered in EOS risk..
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Affiliation(s)
- Kelley M Sonney
- Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Dakota Tomasini
- Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - James K Aden
- Department of Pediatrics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Caitlin M Drumm
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Malviya MN, Murthi S, Selim AA, Malik F, Jayraj D, Mendoza J, Ramdas V, Rasheed S, Jabri AA, Sabri RA, Asiry SA, Yahmadi MA, Shah PS. A Neonatologist-Driven Antimicrobial Stewardship Program in a Neonatal Tertiary Care Center in Oman. Am J Perinatol 2024; 41:e747-e754. [PMID: 36037856 DOI: 10.1055/a-1933-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The overuse of antimicrobials in neonates is not uncommon and has resulted in a global health crisis of antibiotic resistance. This study aimed to evaluate changes associated with a neonatologist-driven antimicrobial stewardship program (ASP) in antibiotic usage. STUDY DESIGN We conducted a pre-post retrospective cohort study in a tertiary care hospital in Oman. Neonates admitted in 2014 to 2015 were considered as the pre-ASP cohort. In 2016, a neonatologist-driven ASP was launched in the unit. The program included the optimization and standardization of antibiotic use for early- and late-onset sepsis using the Centers for Disease Control and Prevention's "broad principles," an advanced antimicrobial decision-support system to resolve contentious issues, and placed greater emphasis on education and behavior modification. Data from the years 2016 to 2019 were compared with previous data. The outcome of interest included days of therapy (DOT) for antimicrobials. Baseline characteristics and outcomes were compared using standard statistical measures. RESULTS The study included 2,098 neonates in the pre-ASP period and 5,464 neonates in the post-ASP period. There was no difference in baseline characteristics. The antibiotic use decreased from 752 DOT per 1,000 patient-days (PD) in the pre-ASP period to 264 DOT in the post-ASP period (64.8% reduction, p < 0.001). The proportion of neonates who received any antibiotics declined by 46% (pre-ASP = 1,161/2,098, post-ASP = 1,676/5,464). The most statistically significant reduction in DOT per 1,000 PD was observed in the use of cefotaxime (82%), meropenem (74%), and piperacillin-tazobactam (74%). There was no change in mortality, culture-positive microbial profile, or multidrug-resistant organism incidence in the post-ASP period. CONCLUSION Empowering frontline neonatologists to drive ASPs was associated with a sustained reduction in antibiotic utilization. KEY POINTS · Overuse of antimicrobials is not uncommon in neonatal intensive care units.. · ASPs and infection control and prevention measures may help in decreasing antibiotic consumption and culture-positive sepsis.. · Empowering frontline neonatologists resulted in a sustained decrease in antimicrobial use without extra resources or financial burden..
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Affiliation(s)
| | | | - Ahmed A Selim
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Fadia Malik
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Dhanya Jayraj
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Julet Mendoza
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Vidhya Ramdas
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Sohail Rasheed
- Department of Information and Technology, Khoula hospital, Muscat, Oman
| | - Amal Al Jabri
- Department of Microbiology, Khoula hospital, Muscat, Oman
| | - Raid Al Sabri
- Department of Pharmacy, Khoula hospital, Muscat, Oman
| | | | | | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai hospital, Toronto, Canada
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林 梅, 张 雪, 王 亚, 朱 晓, 薛 江. [Interpretation of the key updates in the 2022 European guideline on the management of neonatal respiratory distress syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:779-784. [PMID: 37668023 PMCID: PMC10484088 DOI: 10.7499/j.issn.1008-8830.2303046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/12/2023] [Indexed: 09/06/2023]
Abstract
With the deepening of clinical research, the management of neonatal respiratory distress syndrome (RDS) needs to be optimized and improved. This article aims to introduce the 2022 European guideline on the management of neonatal RDS, focusing on its key updates. The guide has optimized the management of risk prediction for preterm birth, maternal referral, application of prenatal corticosteroids, application of lung protective ventilation strategies, and general care for infants with RDS. The guideline is mainly applicable to the management of RDS in neonates with gestational age greater than 24 weeks.
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Ou-Yang MC, Hsu JF, Chu SM, Chang CM, Chen CC, Huang HR, Yang PH, Fu RH, Tsai MH. Influences of Initial Empiric Antibiotics with Ampicillin plus Cefotaxime on the Outcomes of Neonates with Respiratory Failure: A Propensity Score Matched Analysis. Antibiotics (Basel) 2023; 12:445. [PMID: 36978311 PMCID: PMC10044461 DOI: 10.3390/antibiotics12030445] [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: 01/13/2023] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
Background: Empiric antibiotics are often prescribed in critically ill and preterm neonates at birth until sepsis can be ruled out. Although the current guideline suggests narrow-spectrum antibiotics, an upgrade in antibiotics is common in the neonatal intensive care unit. The impacts of initial broad-spectrum antibiotics on the outcomes of critically ill neonates with respiratory failure requiring mechanical intubation have not been well studied. Methods: A total of 1162 neonates from a tertiary level neonatal intensive care unit (NICU) in Taiwan who were on mechanical ventilation for respiratory distress/failure at birth were enrolled, and neonates receiving ampicillin plus cefotaxime were compared with those receiving ampicillin plus gentamicin. Propensity score-matched analysis was used to investigate the effects of ampicillin plus cefotaxime on the outcomes of critically ill neonates. Results: Ampicillin plus cefotaxime was more frequently prescribed for intubated neonates with lower birth weight, higher severity of illness, and those with a high risk of early-onset sepsis. Only 11.1% of these neonates had blood culture-confirmed early-onset sepsis and/or congenital pneumonia. The use of ampicillin plus cefotaxime did not significantly contribute to improved outcomes among neonates with early-onset sepsis. After propensity score-matched analyses, the critically ill neonates receiving ampicillin plus cefotaxime had significantly worse outcomes than those receiving ampicillin plus gentamicin, including a higher risk of late-onset sepsis caused by multidrug-resistant pathogens (11.2% versus 7.1%, p = 0.027), longer duration of hospitalization (median [IQR], 86.5 [47-118.8] days versus 78 [45.0-106.0] days, p = 0.002), and a significantly higher risk of in-hospital mortality (14.2% versus 9.6%, p = 0.023). Conclusions: Ampicillin plus cefotaxime should not be routinely prescribed as the empiric antibiotics for critically ill neonates at birth because they were associated with a higher risk of infections caused by multidrug-resistant pathogens and final worse outcomes.
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Affiliation(s)
- Mei-Chen Ou-Yang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Jen-Fu Hsu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shih-Ming Chu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ching-Min Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Pediatric Gastrointestinal Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Chih-Chen Chen
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Hsuan-Rong Huang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Peng-Hong Yang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Pediatric Gastrointestinal Disease, Department of Pediatrics, Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Ren-Huei Fu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Horng Tsai
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 147] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Abstract
Early-onset sepsis can cause significant morbidity and mortality in newborn infants. Risk factors for sepsis include birth to mothers with inadequately treated maternal group B Streptococcus colonization, intra-amniotic infection, maternal temperature greater than 100.4°F (>38°C), rupture of membranes greater than 18 hours, and preterm labor. The organisms that most commonly cause early-onset sepsis include group B Streptococcus, Escherichia coli, and viridans streptococci. Infants often present within the first 24 hours after birth with clinical signs of sepsis, with respiratory distress as the most common presenting symptom. However, infants can also have respiratory distress from noninfectious etiologies. Therefore, when physicians are faced with asymptomatic infants with risk factors or infants with respiratory distress without risk factors, there is a delicate balance between empirically treating with antibiotics and observing these infants without treating.
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Affiliation(s)
- Courtney Briggs-Steinberg
- Division of Neonatology, Department of Pediatrics, Staten Island University Hospital, Northwell Health, Staten Island, NY.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Philip Roth
- Division of Neonatology, Department of Pediatrics, Staten Island University Hospital, Northwell Health, Staten Island, NY.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Zihlmann-Ji J, Braun C, Buettcher M, Hodel M, Lehnick D, Stocker M. Reduction of Duration of Antibiotic Therapy for Suspected Early-Onset Sepsis in Late-Preterm and Term Newborns After Implementation of a Procalcitonin-Guided Algorithm: A Population-Based Study in Central Switzerland. Front Pediatr 2021; 9:702133. [PMID: 34368029 PMCID: PMC8339316 DOI: 10.3389/fped.2021.702133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Suspected early-onset sepsis (EOS) is the main reason for antibiotic therapy at the start of life. Prolonged antibiotic therapy for culture-negative sepsis is often reported. Antibiotic stewardship is mandatory due to the potential negative effects of unnecessary antibiotics. Procalcitonin (PCT)-guided therapy is one possible strategy with published evidence to shorten antibiotic therapy. The aim of this study is to analyze the feasibility and the performance of the published PCT-algorithm in the clinical setting without study support. Methods: This is a retrospective, population-based study regarding duration of antibiotic therapy for suspected EOS in Central Switzerland between 2014 and 2018. All neonates >34 0/7 weeks of gestational age started on antibiotic therapy for suspected EOS within the first 3 calendar days of life were included. The Procalcitonin-guided algorithm according to the NeoPInS study was used as strategy to determine duration of antibiotic therapy. Results: In a population-based cohort of 35,642 life born neonates, the duration of antibiotic therapy of 879 neonates (2.5% of the cohort) treated for suspected EOS was 4 calendar days (median, IQR 2-5). We observed a statistically significant reduction from 4 (median, IQR 3-6) to 3 calendar days (median, IQR 2-4) from 2014 to 2018. Duration of antibiotic therapy was independent of gestational age (late-preterm vs. term neonates), of the presence of risk factors or clinical signs, but dependent on the presence of abnormal laboratory measurements (C-reactive protein > 10 mg/l or leukocytopenia <5 Giga/l) before start of antibiotic therapy (p < 0.01). Conclusions: PCT-guided therapy using the NeoPInS algorithm is feasible and may lead to reduced duration of antibiotic therapy for suspected EOS as reported in the original study. We observed a learning curve to the new algorithm which may be explained as change process. The use of biomarker to guide duration of antibiotic therapy for suspected EOS may have unintended consequences with prolongation of antibiotic therapy in some cases.
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Affiliation(s)
- Jennifer Zihlmann-Ji
- Department of Paediatrics, Neonatal and Paediatric Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland.,Department of Gynaecology and Obstetrics, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Christian Braun
- Department of Gynaecology and Obstetrics, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Michael Buettcher
- Department of Paediatrics, Neonatal and Paediatric Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
| | - Markus Hodel
- Department of Gynaecology and Obstetrics, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Dirk Lehnick
- Department of Biostatistics, University of Lucerne, Lucerne, Switzerland
| | - Martin Stocker
- Department of Paediatrics, Neonatal and Paediatric Intensive Care Unit, Children's Hospital Lucerne, Lucerne, Switzerland
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