1
|
Fung TY, Sahota DS. How can we reduce neonatal sepsis after universal group B streptococcus screening? BMC Pregnancy Childbirth 2024; 24:586. [PMID: 39244582 PMCID: PMC11380416 DOI: 10.1186/s12884-024-06791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Group B Streptococcus (GBS) infection remains a leading cause of newborn morbidity and mortality. The study aimed to determine the adherence rate to the universal screening policy a decade after its introduction. Secondly, whether the timing of antibiotics given in GBS carriers reduces the incidence of neonatal sepsis. METHODS Delivery records at Hong Kong Baptist Hospital in 2022 were examined to retrieve antenatal and intrapartum details regarding maternal GBS carrier status, previous maternal GBS carrier status, antibiotic treatment, timing of treatment, neonatal condition at birth and whether the neonate had sepsis. Univariate statistics was used to assess the relationship between maternal GBS carrier and neonatal sepsis overall. Incidence of neonatal sepsis was stratified according to mode of delivery and timing of antibiotic. RESULTS The adherence rate to the universal GBS screening policy was 97%. The risk of neonatal sepsis was 5.45 (95% CI 3.05 to 9.75) times higher in women who were GBS screened positive when compared to non-GBS carriers (p < 0.001). Amongst term neonates from GBS carriers delivered by Caesarean section, the risk of neonatal sepsis significantly decreased by 70% after antenatal antibiotic treatment (p = 0.041) whereas in term neonates delivered vaginally, the risk of neonatal sepsis decreased by 71% (p = 0.022) if intrapartum antibiotic prophylaxis was given 4 or more hours. CONCLUSION Giving antenatal antibiotic treatment before Caesarean section or intrapartum antibiotic prophylaxis for 4 or more hours before vaginal delivery may decrease the risk of neonatal sepsis in term neonates delivered from GBS carriers.
Collapse
Affiliation(s)
- Tak Yuen Fung
- Department of Obstetrics and Gynaecology, Hong Kong Baptist Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynaecology, Hong Kong Baptist Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
2
|
Miao S, Yin J, Liu S, Zhu Q, Liao C, Jiang G. Maternal-Fetal Exposure to Antibiotics: Levels, Mother-to-Child Transmission, and Potential Health Risks. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2024; 58:8117-8134. [PMID: 38701366 DOI: 10.1021/acs.est.4c02018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Due to its widespread applications in various fields, antibiotics are continuously released into the environment and ultimately enter the human body through diverse routes. Meanwhile, the unreasonable use of antibiotics can also lead to a series of adverse outcomes. Pregnant women and developing fetuses are more susceptible to the influence of external chemicals than adults. The evaluation of antibiotic exposure levels through questionnaire surveys or prescriptions in medical records and biomonitoring-based data shows that antibiotics are frequently prescribed and used by pregnant women around the world. Antibiotics may be transmitted from mothers to their offspring through different pathways, which then adversely affect the health of offspring. However, there has been no comprehensive review on antibiotic exposure and mother-to-child transmission in pregnant women so far. Herein, we summarized the exposure levels of antibiotics in pregnant women and fetuses, the exposure routes of antibiotics to pregnant women, and related influencing factors. In addition, we scrutinized the potential mechanisms and factors influencing the transfer of antibiotics from mother to fetus through placental transmission, and explored the adverse effects of maternal antibiotic exposure on fetal growth and development, neonatal gut microbiota, and subsequent childhood health. Given the widespread use of antibiotics and the health threats posed by their exposure, it is necessary to comprehensively track antibiotics in pregnant women and fetuses in the future, and more in-depth biological studies are needed to reveal and verify the mechanisms of mother-to-child transmission, which is crucial for accurately quantifying and evaluating fetal health status.
Collapse
Affiliation(s)
- Shiyu Miao
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Jia Yin
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Shuang Liu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Qingqing Zhu
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Chunyang Liao
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- Hubei Key Laboratory of Environmental and Health Effects of Persistent Toxic Substances, School of Environment and Health, Jianghan University, Wuhan 430056, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Guibin Jiang
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, China
- School of Environment, Hangzhou Institute for Advanced Study, UCAS, Hangzhou 310024, China
- Hubei Key Laboratory of Environmental and Health Effects of Persistent Toxic Substances, School of Environment and Health, Jianghan University, Wuhan 430056, China
- College of Resources and Environment, University of Chinese Academy of Sciences, Beijing 100049, China
| |
Collapse
|
3
|
Wang Z, Xiu X, Zhong L, Wang Y, Fang Z, Lin S, Huang H. Significance of cervical secretion culture in predicting maternal and fetal outcome in pregnant women with premature rupture of membranes: a retrospective cohort study. Front Pharmacol 2024; 15:1328107. [PMID: 38455965 PMCID: PMC10917918 DOI: 10.3389/fphar.2024.1328107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/07/2024] [Indexed: 03/09/2024] Open
Abstract
Background: To investigate the clinical value of cervical secretion culture in pregnant women with premature rupture of membranes (PROM) in predicting maternal and fetal outcomes. Methods: We retrospectively reviewed clinical records of pregnant women who underwent obstetric examination and delivered in Fujian Maternal and Child Healthcare from December 2013 to December 2016. Pregnant women with a clear diagnosis of PROM, who underwent cervical secretion culture immediately after hospital admission were selected for the study. The primary outcome was the occurrence of chorioamnionitis. The secondary outcome was neonatal admission to the neonatal intensive care unit (NICU). Correlation between maternal and fetal outcomes and the results of the cervical secretion culture was analyzed by one-way analysis and multifactorial analysis, respectively. The predictive efficacy of cervical secretion culture was evaluated using receiver operating characteristic curve (ROC), area under the curve (AUC) and the integrated discrimination improvement (IDI). Results: A total of 7,727 pregnant women with PROM were included in the study. Of them, 1812 had positive cervical secretion cultures (635 positive for mycoplasma infection, 475 for bacterial, 637 for fungal, and 65 for chlamydial infections). Pregnant women with positive mycoplasma and bacterial cultures had higher rates of developing chorioamnionitis compared to women with negative cervical secretion cultures (9%, 12% vs. 1%, respectively). Similarly, positive mycoplasma and bacterial cultures were associated with higher rate of the preterm (before 34 weeks) labor (3%, 3% vs. 1% in women with negative cultures, respectively), and neonatal admission to the NICU (9%, 11% vs. 7%, respectively). After adjusting for various confounding factors, our analysis demonstrated that a positive cervical secretion culture for mycoplasma or bacterial pathogens remained an independent risk factor for chorioamnionitis. Cervical secretion culture outcome was less effective in predicting chorioamnionitis (AUC 0.569) compared to white blood count (WBC) (AUC 0.626) and C-reactive protein (CRP) levels (AUC 0.605). The IDI of the combined predictive model incorporating WBC, CRP, maternal fever and cervical secretion culture results was 0.0029. Conclusion: Positive cervical secretion cultures, especially for mycoplasma and bacteria, are associated with higher incidence of adverse maternal and fetal outcomes. However, the predictive value of this test is poor, and cannot be efficiently used for predicting chorioamnionitis.
Collapse
|
4
|
Grief MM, Yamamoto LG. Approach to the Febrile Infant (<3 Months). Pediatr Emerg Care 2023; 39:875-879. [PMID: 37902653 DOI: 10.1097/pec.0000000000003064] [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: 10/31/2023]
Abstract
ABSTRACT Evaluation and management of the febrile infant has long been an area of variability. Recent guidelines were released by the American Academy of Pediatrics in August 2021 to help provide evidence-based clinical guidelines to decrease variability and improve outcomes.1 These guidelines largely focus on management and treatment guidelines for 3 age groups: 8 to 21 days, 22 to 28 days, and 29 to 60 days. The inclusion criteria for these guidelines are previously healthy, term infants born at 37 weeks gestation or later, with a temperature of 100.4°F (38°C) or higher. The most significant changes to historical practice are in the 22- to 28-day and 29- to 60-day age groups. If initial laboratory work is reassuring, patients may not need cerebrospinal fluid studies, and patients may be monitored at home or at the hospital using shared decision-making with the family.
Collapse
Affiliation(s)
| | - Loren G Yamamoto
- Professor of Pediatrics, University of Hawai'i John A. Burns School of Medicine and Kapi'olani Medical Center For Women & Children, Honolulu, HI
| |
Collapse
|
5
|
Minotti C, Di Caprio A, Facchini L, Bedetti L, Miselli F, Rossi C, Della Casa Muttini E, Lugli L, Luppi L, Ferrari F, Berardi A. Antimicrobial Resistance Pattern and Empirical Antibiotic Treatments in Neonatal Sepsis: A Retrospective, Single-Center, 12-Year Study. Antibiotics (Basel) 2023; 12:1488. [PMID: 37887188 PMCID: PMC10604095 DOI: 10.3390/antibiotics12101488] [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: 08/23/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Neonatal sepsis is an important cause of morbidity and mortality in neonatal intensive care units (NICUs). Continuous evaluation of antimicrobial resistance (AMR) profiles is advised to implement antimicrobial stewardship (AMS) programs and establish effective empiric antibiotic protocols. AMS may reduce AMR in NICUs and improve sepsis outcomes. In this retrospective observational study, we report data on culture-positive neonatal sepsis, assessing differences after the implementation of an AMS program (2011-2016 vs. 2017-2022). A total of 215 positive bacterial cultures from 169 infants were retrieved, with 79 early-onset (36.7%) and 136 late-onset (63.3%) sepsis episodes. Frequent causative agents for early-onset sepsis were S. agalactiae and E. coli, all susceptible to empiric treatment. Late-onset sepsis was mainly caused by Enterobacterales and S. aureus. Aminoglycosides, cefotaxime, and piperacillin-tazobactam resistance among Enterobacterales was substantially low; S. aureus was mostly susceptible to oxacillin and vancomycin. There were no differences in mortality and multidrug-resistant pathogens rates between the two study periods. There were five episodes of fungal late-onset sepsis, mostly due to C. albicans, of which one was fatal. The microbial distribution pattern and AMR profiles overlapped with other European studies. Because susceptibility patterns are rapidly changing worldwide, with the emerging threat of Methicillin-resistant S. aureus and extended-spectrum beta-lactamases producers, infection prevention and control practices and AMS strategies require continuous optimization to limit selection pressure and AMR escalation.
Collapse
Affiliation(s)
- Chiara Minotti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
- PhD Program in Clinical Research, University Children’s Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Antonella Di Caprio
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Laura Facchini
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Luca Bedetti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Francesca Miselli
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Cecilia Rossi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Elisa Della Casa Muttini
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Licia Lugli
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| | - Laura Luppi
- Clinical Microbiology Unit, University Hospital of Modena, 41124 Modena, Italy
| | - Filippo Ferrari
- Clinical Microbiology Unit, University Hospital of Modena, 41124 Modena, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy or (C.M.); (L.F.); (L.B.); (F.M.); (C.R.); (E.D.C.M.); (L.L.); (A.B.)
| |
Collapse
|
6
|
Bitnun A, Sauvé L, Fanella S. Reducing perinatal infection risk in newborns of mothers who received inadequate prenatal care. Paediatr Child Health 2023; 28:307-323. [PMID: 37484040 PMCID: PMC10362956 DOI: 10.1093/pch/pxad014] [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: 11/25/2021] [Accepted: 11/23/2022] [Indexed: 07/25/2023] Open
Abstract
Inadequate prenatal care increases risk for maternal infections going undetected and untreated, putting both the mother's health and that of her infant at risk. When pregnant women present late to care, routine testing that impacts infant management should include: hepatitis B surface antigen (HBsAg); serology for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis; and testing for Chlamydia trachomatis and Neisseria gonorrhoeae. If the mother was not tested before or after delivery and is not available for testing, the infant should undergo testing for HIV, HBV, HCV, and syphilis. Testing for C. trachomatis and N. gonorrhoeae should be undertaken if the infant develops compatible clinical manifestations. Rapid turnaround of test results for HIV, HBV, and syphilis is optimal because preventive treatment decisions are time-sensitive. Early and effective preventive interventions are available for newborns at risk for HIV, HBV, syphilis, or gonorrhea. Close clinical follow-up and follow-up testing of infants born to mothers with inadequate prenatal care are warranted, as not all infections can be fully excluded perinatally.
Collapse
Affiliation(s)
- Ari Bitnun
- Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Ottawa, Ontario, Canada
| | - Laura Sauvé
- Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Ottawa, Ontario, Canada
| | - Sergio Fanella
- Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Ottawa, Ontario, Canada
| |
Collapse
|
7
|
Spénard E, Tordjman L, Marrié-Mas AE, Dal Soglio D, Eberle A, Labbé AC, Boucoiran I. Evaluation of a clinical protocol for the management of fever in labor among pregnant women at term: A quality-improvement study. Int J Gynaecol Obstet 2023; 161:225-233. [PMID: 36181701 DOI: 10.1002/ijgo.14488] [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] [Revised: 09/02/2022] [Accepted: 09/25/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the impact of a quality-improvement initiative designed to increase diagnostic accuracy and adequate management of clinical chorioamnionitis (CC) at a tertiary center. Chorioamnionitis occurs in 1%-13% of term pregnancies and increases maternal and neonatal peripartum complications; often over-diagnosed, it leads to unnecessary investigations and treatments. METHODS This was an interrupted time-series study. In September 2017 two interventions were implemented: (1) staff training and (2) standardized clinical protocol for the management of fever in labor. All singleton term pregnancies were included. CC cases were reviewed in the pre-intervention (2015-2016, n = 179) and post-intervention (2017-2018, n = 142) groups. CC criteria based on the American College of Obstetricians and Gynecologists guidelines, antibiotics, maternal and neonatal outcomes, and pathology were compared. A cost-consequence analysis was performed. RESULTS Incidence of CC decreased from 8.2 to 5.6 per 10 person-year (P < 0.001). This was associated with a significant increase in diagnostic accuracy from 15.7% to 73.2% (P < 0.001). Weight-adjusted tobramycin dosage improved from 8.8% to 69.1% (P < 0.001). Maternal length of hospitalization and readmissions decreased significantly, without affecting neonatal sepsis rate. Interventions decreased yearly hospital costs associated with CC by 23.4%. CONCLUSION Standardizing the management of fever in labor significantly increased the diagnostic accuracy of CC and decreased the misuse of antibiotics in term pregnancies. CC costs decreased by 23.4%.
Collapse
Affiliation(s)
- Elisabeth Spénard
- Department of Obstetrics and Gynecology, Université de Montréal, Montreal, Québec, Canada
| | - Laurent Tordjman
- Department of Obstetrics and Gynecology, Université de Montréal, Montreal, Québec, Canada.,Department of Obstetrics and Gynecology, Hôpital Maisonneuve-Rosemont, CIUSSS EMTL, Montreal, Québec, Canada
| | | | | | - Alexa Eberle
- Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Annie-Claude Labbé
- Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Québec, Canada.,Service of Infectious Diseases, Hôpital Maisonneuve-Rosemont, CIUSSS EMTL, Montreal, Québec, Canada
| | - Isabelle Boucoiran
- Department of Obstetrics and Gynecology, Université de Montréal, Montreal, Québec, Canada.,Mother and Child Infectious Disease Centre, Department of Obstetrics and Gynecology, CHU Sainte-Justine, Montreal, Québec, Canada.,School of Public Health, Université de Montréal, Montreal, Québec, Canada
| |
Collapse
|
8
|
Coveney J, O'Loughlin J, Ainle FN, Drew RJ, Boyle MA. The full blood count in screening asymptomatic infants for early-onset sepsis: A cross-sectional study. Acta Paediatr 2023; 112:385-390. [PMID: 36420582 DOI: 10.1111/apa.16602] [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: 10/18/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022]
Abstract
AIM The full blood count (FBC) is commonly measured as part of a partial septic work-up in asymptomatic infants at increased risk of early-onset neonatal sepsis (EOS). To determine the impact of FBC parameters on infants' subsequent management a retrospective cross-sectional study was performed. METHODS Infants, born at ≥34 weeks gestation, asymptomatic at birth, undergoing a partial septic work-up and receiving prophylactic antibiotics due to increased risk of EOS in a single centre over a 2-year period, were included. The primary outcome measure was frequency of FBC result impacting on duration of antibiotic therapy. Secondary outcome measures included frequency of FBC parameters outside of the reference range and incidental diagnoses. RESULTS In total, 16 726 live-born infants were delivered during the study period. A total of 802 (4.8%) were included. Thirteen infants (1.6%) received a prolonged course of antibiotics due to suspicion for EOS. Two of these infants had elevated white cell counts. All had normal neutrophil counts. In no case did the FBC result influence the decision to prolong the antibiotic course. CONCLUSION In a cohort of 802 infants, asymptomatic at birth and at increased risk of EOS, the FBC result did not impact on the decision to prolong the course of antibiotics for suspicion of EOS.
Collapse
Affiliation(s)
- John Coveney
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| | - John O'Loughlin
- Department of Laboratory Medicine, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala Ní Ainle
- Department of Haematology, Rotunda Hospital, Dublin, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Richard J Drew
- Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland.,Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland, Dublin, Ireland.,Department of Clinical Microbiology, Royal college of Surgeons, Dublin, Ireland
| | - Michael A Boyle
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland.,Department of Neonatology, Children's Health Ireland, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons, Dublin, Ireland
| |
Collapse
|
9
|
Rød E, Solberg V, Stenersen EO, Garberg HT, Mjelle AB, Tølløfsrud PA, Rønnestad AE, Solevåg AL. Biochemical surveillance versus clinical observation of term infants born after prolonged rupture of membranes - A quality assurance initiative. Acta Paediatr 2023; 112:391-397. [PMID: 36478463 PMCID: PMC10107997 DOI: 10.1111/apa.16617] [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: 10/17/2022] [Revised: 11/23/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
AIM To examine whether biochemical surveillance vs clinical observation of term infants with prolonged rupture of membranes as a risk factor for early-onset sepsis is associated with differences in patient trajectories in maternity and neonatal intensive care units. METHODS A retrospective study of live-born infants with gestational age ≥ 37 + 0 weeks born after prolonged rupture of membranes (≥24 h) in four Norwegian hospitals 2017-2019. Two hospitals used biochemical surveillance, and two used predominantly clinical observation to identify early-onset sepsis cases. RESULTS The biochemical surveillance hospitals had more C-reactive protein measurements (p < 0.001), neonatal intensive care unit admissions (p < 0.001) and antibiotic treatment (p < 0.001). Hospitals using predominantly clinical observation initiated antibiotic treatment earlier in infants with suspected early-onset sepsis (p = 0.04) but not in infants fulfilling early-onset sepsis diagnostic criteria (p = 0.09). There was no difference in antibiotic treatment duration (p = 0.59), fraction of infants fulfilling early-onset sepsis diagnostic criteria (p = 0.49) or length of hospitalisation (p = 0.30), and no early-onset sepsis-related adverse outcomes. CONCLUSION The biochemical surveillance hospitals had more C-reactive protein measurements, but there was no difference in antibiotic treatment duration, early-onset sepsis cases, length of hospitalisation or adverse outcomes. Personnel resources needed for clinical surveillance should be weighed against the limitation of potentially painful procedures.
Collapse
Affiliation(s)
- Emma Rød
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Vilde Solberg
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Eydís Oddsdóttir Stenersen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Institute of clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Anders Batman Mjelle
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Per Arne Tølløfsrud
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Arild Erland Rønnestad
- Institute of clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
10
|
Kayser N, Cunningham K, Alabsi S, Smith H. Targeting Lower Serum Trough Concentrations: A New Gentamicin Dosing Strategy for Suspected Neonatal Early-Onset Sepsis. J Pediatr Pharmacol Ther 2023; 28:71-77. [PMID: 36777986 PMCID: PMC9901316 DOI: 10.5863/1551-6776-28.1.71] [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: 11/10/2020] [Accepted: 06/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Neonatal gentamicin dosing algorithms are not designed to achieve serum trough concentrations ≤1 mcg/mL. The purpose of our study was to evaluate a new gentamicin algorithm based on serum creatinine (SCr) and gestational age (GA) designed to achieve serum gentamicin trough concentrations ≤1 mcg/mL. METHODS A retrospective cohort study was conducted in a level IIIB neonatal intensive care unit. The incidence of elevated serum gentamicin troughs for this study was compared with the center's previously published results to evaluate the proposed dosing algorithm. Patients were included if gentamicin was administered within the first 7 days of life and a serum gentamicin trough concentration and a baseline SCr concentration were obtained. Patients were further subdivided into groups based on GA for data analysis: ≤30 weeks (group 1), 30-34 weeks (group 2), and ≥35 weeks (group 3). The SCr was considered mildly elevated (0.81-0.99 mg/dL) or elevated (≥1 mg/dL). The respective outcomes between the post-algorithm and control groups were examined using intention-to-treat analysis and Bayesian modeling to calculate rate differences. RESULTS Of the 2377 patients evaluated, 366 met the inclusion criteria. Significantly lower percentages of elevated serum gentamicin troughs were noted in groups 2 and 3 subsequent to the implementation of the dosing algorithm with 16% and 15% lower rate differences, respectively. Regardless of GA, there were significantly fewer elevated serum troughs in the post-implementation groups than in the control with mildly elevated and elevated SCr p < 0.001. CONCLUSIONS Using a dosing algorithm based on SCr significantly reduced the number of elevated serum trough rates in neonates with a GA greater than 30 weeks.
Collapse
Affiliation(s)
- Nicholas Kayser
- Department of Pharmacy (NK, KC), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Kelli Cunningham
- Department of Pharmacy (NK, KC), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Samir Alabsi
- Neonatal Intensive Care Unit (SA), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Hayden Smith
- Education and Research Department (HS), UnityPoint Des Moines–Iowa Methodist Medical Center, Des Moines, IA
| |
Collapse
|
11
|
Decreasing the Rate of Antibiotics Administration to Newborns of Mothers With Prolonged Rupture of Membranes and Unknown Group B Streptococcus Status Using the Plan-Do-Study-Act Quality Improvement Model. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Amer YS, Shaiba LA, Hadid A, Anabrees J, Almehery A, AAssiri M, Alnemri A, Darwish ARA, Baqawi B, Aboshaiqah A, Hneiny L, Almaghrabi RH, El-Malky AM, Al-Dajani NM. Quality assessment of clinical practice guidelines for neonatal sepsis using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument: A systematic review of neonatal guidelines. Front Pediatr 2022; 10:891572. [PMID: 36052365 PMCID: PMC9424847 DOI: 10.3389/fped.2022.891572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objective Neonatal sepsis (NS) continues to be a critical healthcare priority for the coming decades worldwide. The aim of this study was to critically appraise the quality of recent clinical practice guidelines (CPGs) for neonatal sepsis and to summarize and compare their recommendations. Methods This study involves a systematic review of CPGs. We identified clinical questions and eligibility criteria and searched and screened for CPGs using bibliographic and CPG databases and professional societies. Each included CPG was assessed by four independent appraisers using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument. We summarized the recommendations in a comparison practical table. The systematic review was drafted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Its protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42021258732). Results Our search retrieved 4,432 citations; of which five CPGs were eligible and appraised: American Academy of Pediatrics (AAP 2018) (35 and 34 weeks); Canadian Pediatric Society (CPS 2017); National Institute for Health and Care Excellence (NICE 2021); and Queensland Maternity and Neonatal Services (QH 2020). Among these, the overall assessment of two evidence-based CPGs scored > 70% (NICE and QH), which was consistent with their higher scores in the six domains of the AGREE II instrument. In domain 3 (rigor of development), NICE and QH scored 99 and 60%, respectively. In domain 5 (applicability), they scored 96 and 74%, respectively, and in domain 6 (editorial independence), they scored 90 and 71%, respectively. Conclusion The methodological quality of the NICE CPG was superior followed by the QH CPG with relevant recommendations for use in practice. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258732, PROSPERO (CRD42021258732).
Collapse
Affiliation(s)
- Yasser S. Amer
- Pediatrics Department, King Khalid University Hospital, Riyadh, Saudi Arabia
- Clinical Practice Guidelines and Quality Research Unit, Quality Management Department, King Saud University Medical City, Riyadh, Saudi Arabia
- Research Chair for Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh, Saudi Arabia
- Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria, Egypt
- Adaptation Working Group, Guidelines International Network, Perth, Scotland
| | - Lana A. Shaiba
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Neonatal Intensive Care Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Adnan Hadid
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Neonatal Intensive Care Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Jasim Anabrees
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Neonatal Intensive Care Unit, King Saud University Medical City, Riyadh, Saudi Arabia
- Saudi Neonatology Society (SNS), Riyadh, Saudi Arabia
| | | | - Manal AAssiri
- Neonatology Department, King Abdulaziz Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | - Abdulrahman Alnemri
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Neonatal Intensive Care Unit, King Saud University Medical City, Riyadh, Saudi Arabia
- Saudi Neonatology Society (SNS), Riyadh, Saudi Arabia
| | - Amira R. Al Darwish
- Clinical Pharmacy Department, Pharmacy Services, Second Health Cluster in Central Region, Riyadh, Saudi Arabia
- Pharmacy Department, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Badi Baqawi
- Obstetrics and Gynecology Department, King Fahad Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Layal Hneiny
- Saab Medical Library, University Libraries, American University of Beirut, Beirut, Lebanon
- Wegner Health Sciences Library, University of South Dakota, Sioux Falls, SD, United States
| | - Rana H. Almaghrabi
- Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmed M. El-Malky
- Morbidity and Mortality Unit, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
- Public Health and Community Medicine Department, Theodor Bilharz Research Institute (TBRI), Academy of Scientific Research, Cairo, Egypt
| | - Nawaf M. Al-Dajani
- Neonatal Intensive Care Unit, Infectious Diseases Unit, Pediatrics Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| |
Collapse
|
13
|
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..
Collapse
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
| | | |
Collapse
|
14
|
Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
Collapse
Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
15
|
Abu-Raya B, Jost M, Bettinger JA, Bortolussi R, Grabowski J, Lacaze-Masmonteil T, Robinson JL, Posfay-Barbe KM, Galanis E, Schutt E, Mäusezahl M, Kollmann TR. Listeriosis in infants: Prospective surveillance studies in Canada and Switzerland. Paediatr Child Health 2021; 26:e277-e282. [PMID: 34880959 DOI: 10.1093/pch/pxab035] [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: 01/19/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives International data on listeriosis during infancy from large populations are essential to guide evidence-based empiric antibiotic guidelines for sepsis in infancy. We aimed to determine the incidence, clinical manifestations, and outcome of listeriosis in infants <6 months of age in Canada and Switzerland. Methods Prospective, active surveillance of listeriosis in infants <6 months of age was conducted through the Canadian Paediatric Surveillance Program (May 2015 to April 2017) and the Swiss Paediatric Surveillance Unit (April 2017 to March 2018). Confirmed and probable cases were included. Results In Canada, eight sporadic listeriosis cases were reported (incidence, 1.1/100,000 live births/year). In Switzerland, four cases were reported (incidence, 4.5/100,000 live births/year) of which three were part of a confirmed outbreak with an unclear source. In the two countries, eight of the 12 cases (66.6%) presented as early-onset disease (within the first 7 days of life) and none presented after 28 days life. Conclusions Neonatal listeriosis is rare. Infants presenting with sepsis, especially after 4 weeks of life, may not routinely require empiric antibiotic coverage for listeriosis. Outbreak-related cases still occur. Continued surveillance is important.
Collapse
Affiliation(s)
- Bahaa Abu-Raya
- Vaccine Evaluation Center, British Columbia Children's Hospital, Department of Pediatrics, Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia,Canada
| | - Marianne Jost
- Federal Office of Public Health, Department of communicable diseases, Bern, Switzerland
| | - Julie A Bettinger
- Vaccine Evaluation Center, British Columbia Children's Hospital, Department of Pediatrics, Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia,Canada
| | - Robert Bortolussi
- Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Janet Grabowski
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thierry Lacaze-Masmonteil
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Klara M Posfay-Barbe
- Department of Pediatrics, Pediatric Infectious Diseases Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Eleni Galanis
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Mirjam Mäusezahl
- Federal Office of Public Health, Department of communicable diseases, Bern, Switzerland
| | - Tobias R Kollmann
- Vaccine Evaluation Center, British Columbia Children's Hospital, Department of Pediatrics, Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia,Canada
| |
Collapse
|
16
|
Charpentier C, Boucoiran I, McDonald S, Elwood C, Ting J, Grigoriu A, Pylypjuk C, Yudin M, Van Schalkwyk J. A survey on variation in diagnosis and treatment of chorioamnionitis in tertiary centres in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:28-33. [PMID: 34214603 DOI: 10.1016/j.jogc.2021.06.003] [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: 01/22/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Clinical detection and management of chorioamnionitis is challenging given the gold-standard for diagnosis remains placental pathology, the results of which are only available after delivery. Moreover, recommended diagnostic criteria for clinical chorioamnionitis have evolved over time. The goal of this study was to describe trends and differences in chorioamnionitis diagnostic and management practices in Canada. METHODS We surveyed obstetric care providers participating in the Canadian Preterm Birth Network. Questionnaires were distributed electronically to all 29 sites and completed by 1 maternal-fetal medicine investigator at each site. RESULTS The response rate was 82.8% (n = 24). There was considerable variation in the clinical criteria used to diagnose chorioamnionitis with 9 of 22 sites stating this occurs "frequently" or "very frequently." Isolated fever was "always" or "most of the time" used as an indication to start empiric antibiotic therapy in 14 of 24 sites, and 21 of 23 sites used the same diagnostic criteria for term and preterm deliveries. Placental histology (15 sites) and white blood cell count (14 sites) were the most common clinical tests performed to confirm chorioamnionitis. A combination of ampicillin and aminoglycoside antibiotics was used at 12 sites. Another frequently used antibiotic therapy was cefazolin and metronidazole (4 sites). CONCLUSION There is a wide variation in practices for the diagnosis and management of chorioamnionitis across Canada. The results of this study will guide efforts to improve and standardize the management of this condition.
Collapse
Affiliation(s)
| | - Isabelle Boucoiran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université de Montréal, Montreal, Qc, Canada; School of Public Health, Université de Montréal, Montreal, Qc, Canada; Mother and Children Infectious Disease Center, CHU Sainte-Justine Research Center, Montréal, Qc, Canada.
| | - Sarah McDonald
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Radiology and Health Research Methods, Evidence and Impact. McMaster University, Hamilton, ON, Canada
| | - Chealsea Elwood
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| | - Joseph Ting
- Women's Health Research Institute, Vancouver, BC, Canada; Divison of Neonatalogy, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Adriana Grigoriu
- Division of Maternal Fetal Medecine, Department of Obstetric and Gynecology, The Moncton Hospital, Moncton, NB, Canada; Faculty of Medecine, Dalhousie University, Halifax, NS, Canada
| | - Christy Pylypjuk
- Department of Obstetrics, Gynecology and Reproductives sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Mark Yudin
- Obstetrics, Gynecology & Reproductive Infectious Diseases, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada
| | - Julianne Van Schalkwyk
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Women's Health Research Institute, Vancouver, BC, Canada
| |
Collapse
|
17
|
[Sepsis risk calculator-guided antibiotic management in neonates with suspected early-onset sepsis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021. [PMID: 34130779 PMCID: PMC8213997 DOI: 10.7499/j.issn.1008-8830.2101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate the efficacy of sepsis risk calculator (SRC) in guiding antibiotic use in neonates with suspected early-onset sepsis (EOS). METHODS A total of 284 neonates with a gestational age of ≥ 35 weeks were enrolled as the control group, who were hospitalized in the Children's Hospital of Chongqing Medical University from March to July, 2019 and were suspected of EOS. Their clinical data were retrospectively collected and the use of antibiotics was analyzed based on SRC. A total of 170 neonates with a gestational age of ≥ 35 weeks were enrolled as the study group, who were admitted to the hospital from July to November, 2020 and were suspected of EOS. SRC was used prospectively for risk scoring to assist the decision making of clinical antibiotic management. The two groups were compared in terms of the rate of use of antibiotics, blood culture test rate, clinical outcome, and adherence to the use of SRC. RESULTS Compared with the control group, the study group had a significantly higher SRC score at birth and on admission (P < 0.05). The rate of use of antibiotics in the study group was significantly lower than that in the control group[84.7% (144/170) vs 91.5% (260/284), 6.8% decrease; P < 0.05]. The blood culture test rate in the study group was also significantly lower than that in the control group (85.3% vs 91.9%, P < 0.05). There was no significant difference between the two groups in the incidence rate of adverse outcomes and the final diagnosis of EOS (P > 0.05). CONCLUSIONS The use of SRC reduces the rate of empirical use of antibiotics in neonates with suspected EOS and does not increase the risk of adverse outcomes, and therefore, it holds promise for clinical application.
Collapse
|
18
|
Clinical features and outcomes of neonatal dengue at the Children's Hospital 1, Ho Chi Minh, Vietnam. J Clin Virol 2021; 138:104758. [PMID: 33862538 DOI: 10.1016/j.jcv.2021.104758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 11/22/2022]
Abstract
Objectives Neonatal dengue has been reported in the literature with contradictory findings of clinical characteristics and diagnosis; thereby, misdiagnosis of neonatal dengue has been frequently reported. We aim to delve into the epidemiology, clinical features, and outcomes of neonatal dengue, thus avoid misdiagnosis and obtain early intervention. Study design A retrospective study was conducted at Children's Hospital 1, Ho Chi Minh, Vietnam with laboratory-confirmed dengue in neonates by positive viral antigen nonstructural protein one rapid test (NS1) and positive IgM antibody for dengue by MAC-ELISA. Results We have included 32 neonates in this study with 25% cases were misdiagnosed with neonatal sepsis, and 12.5% cases were misdiagnosed with neonatal immune thrombocytopenia at the beginning. The median time between the first day of the mother's onset of fever and childbirth was -1 days (IQR: -2, 2). The patient's clinical manifestation included: petechiae 87.5% (28/32), pharyngeal mucosal hemorrhage 6.3% (2/32), and hepatomegaly occurred 75% (24/32). In the febrile phase (day of illness 1-3), the mean white blood cell (WBC) counts were 7800 ± 800/mm3 and platelets were 97,111 ± 37,826/mm3. In the critical phase (day of illness 4-6), the mean WBC counts were 13,400 ± 2800/mm3, and platelets were 30,100 ± 5749/mm3. All mothers (100%) had laboratory-confirmed dengue by NS1 positive in the perinatal period. Conclusions The findings emphasize that early diagnosis of neonatal dengue should be based on a history of maternal illness, NS1 rapid test, and clinical presentation such as petechiae, hepatomegaly, and low platelet counts in the febrile phase.
Collapse
|
19
|
Ehman D, Mugarab Samedi V, Kalaniti K, Daspal S. Neonatal Escherichia coli infection in twins: clinical spectrum and management dilemma. BMJ Case Rep 2021; 14:14/1/e238470. [PMID: 33504527 PMCID: PMC7843350 DOI: 10.1136/bcr-2020-238470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The clinical manifestation of Escherichia coli could vary from asymptomatic bacteraemia to systemic bloodstream infection and meningitis. We describe an unusual course of E. coli infection in twins, emphasising commencement of appropriate antimicrobial therapy. A set of male dichorionic diamniotic twins were delivered at 34 weeks of gestation by caesarian section. Pregnancy was complicated by diabetes, pre-eclampsia and cholestasis. Antenatal ultrasounds noted a congenital pulmonary airway malformation in twin A. Following delivery, twin A developed respiratory distress, but twin B was asymptomatic. Partial septic work-up at admission in the neonatal intensve care unit was done. Twin A's blood culture grew E. coli, while twin B's blood culture was negative. Twin A was treated with 7 days of intravenous antibiotics. At 11 days of age, twin B acutely developed a scrotal swelling. On suspicion of testicular torsion, he was taken for urgent surgery, which revealed a scrotal abscess positive for E. coli The scrotum was irrigated and successfully treated with 4 weeks of antibiotics. Both twins were doing well at 3 months of follow-up.
Collapse
Affiliation(s)
- Dylan Ehman
- Royal University Hospital, Saskatoon, Saskatchewan, Canada.,College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Veronica Mugarab Samedi
- Royal University Hospital, Saskatoon, Saskatchewan, Canada .,College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kaarthigeyan Kalaniti
- Royal University Hospital, Saskatoon, Saskatchewan, Canada.,College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Sibasis Daspal
- Royal University Hospital, Saskatoon, Saskatchewan, Canada.,College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| |
Collapse
|
20
|
Cabaret B, Latry V. Application of HAS 2017 guidelines for asymptomatic neonates born at ≥34 weeks' gestation at risk of early-onset neonatal sepsis in a level-2 maternity department. Arch Pediatr 2021; 28:159-165. [PMID: 33446432 DOI: 10.1016/j.arcped.2020.12.007] [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: 03/27/2020] [Revised: 08/30/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Abstract
The 2017 Haute Autorité de santé (HAS) guidelines for the medical care of neonates born at≥34 weeks' gestation (WG) at risk of early-onset neonatal sepsis (EONS) placed emphasis on clinical examination rather than laboratory tests. AIM Were these guidelines relevant in our level-2 maternity department, and how can they affect our professional practice? METHODS Single-site observational study of asymptomatic 35 WG neonates at risk of EONS, born in the centre hospitalier de Bigorre, with follow-up analysis during two 5-month periods (from September 2017 to January 2018, and September 2018 to January 2019), before and after the publication of the HAS guidelines. The main objective was feasibility, evaluated by checking the completion of a standardised assessment chart. The second objective was the impact of the guidelines on professional practices evaluated by the number of laboratory tests carried out during the two periods. RESULTS Out of 455 births during the first period and the 396 births during the second, 78 (17,1%) and 50 (12,6%) newborns, respectively, at risk of EONS were included. Those two groups had statistically similar characteristics. Overall, 49 (98%) assessment charts were satisfactorily completed for the 50 newborns. The number of laboratory tests decreased significantly (P<0.01): During the first period, all the newborns (78, 100%) had a C-reactive protein (CRP) test and 66 (84,6%) had a gastric fluid culture, versus one (2%) CRP and three (6%) gastric fluid cultures during the second period. CONCLUSION The HAS guidelines, emphasising repeated clinical assessment of newborns at risk of EONS rather than laboratory, were considered to be feasible in our maternity department. They led to an improvement in our professional practices and a reduction in laboratory procedures.
Collapse
Affiliation(s)
- B Cabaret
- Pediatric department, CH de Bigorre, boulevard de Lattre-de-Tassigny, 65000 Tarbes, France.
| | - V Latry
- Research department, CH de Bigorre, boulevard de Lattre-de-Tassigny, 65000 Tarbes, France
| |
Collapse
|
21
|
Jiang S, Qian Y, Wang Q, Ling Y, Hu Q. Evaluation of the diagnostic value of gastric juice aspirate culture for early-onset sepsis in newborns 28–35 weeks' gestation. Diagn Microbiol Infect Dis 2020; 98:115115. [DOI: 10.1016/j.diagmicrobio.2020.115115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
|
22
|
Gyllensvärd J, Ingemansson F, Hentz E, Studahl M, Elfvin A. C-reactive protein- and clinical symptoms-guided strategy in term neonates with early-onset sepsis reduced antibiotic use and hospital stay: a quality improvement initiative. BMC Pediatr 2020; 20:531. [PMID: 33218324 PMCID: PMC7678045 DOI: 10.1186/s12887-020-02426-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/10/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Early-onset sepsis (EOS) is a potentially life-threatening complication of birth. Clinical symptoms are often unspecific and biomarkers have low predictive values for EOS. Therefore, clinical suspicion often leads to antibiotic therapy in neonates with a negative blood culture. In the study we evaluated if a quality improvement initiative could reduce unwarranted antibiotic use in a safe way in term neonates with culture-negative sepsis. METHODS The quality improvement initiative included new treatment guidelines and were introduced on 11 June 2018. The guidelines included C-reactive protein- and clinical symptoms-guided decision-making and shorter intravenous antibiotic therapy. All term neonates treated for EOS at Ryhov Hospital, Jönköping, Sweden were studied before (period 1: 2016-2017) and after the introduction of the new guidelines (period 2: 11 June 2018 to 30 Sept 2019). Laboratory and clinical data were analysed. RESULTS There were 7618 term neonates in period 1 and 5005 term neonates in period 2. We identified 140 (1.8%) EOS in period 1 and 97 (1.9%) EOS in period 2. During period 1 and 2, there were 61 (61/140, 44%) and 59 (59/97, 61%) EOS neonates, respectively, who met the criteria for shorter antibiotic treatment. The number of positive blood cultures were seven (0.92/1000 live births) and five (1.0/1000 live births) in period 1 and 2. The median C-reactive protein were 52 mg/L (37-62) in period 1 and 42 mg/L (31-56) in period 2 in the group who met the criteria of the guidelines. The duration of antibiotic therapy (Median: seven vs. five days, p < 0.001) and hospital stay (Median: seven vs. five days, p < 0.001) as well as healthcare costs (decreased by €122,000/year) was reduced in the group who met the criteria after the introduction of the guidelines. CONCLUSION C-reactive protein- and clinical symptoms-guided decision-making for EOS significantly decreased the duration of antibiotic therapy and hospital stay, and hence reduced healthcare costs, with no reinfection in a cohort of term infants. TRIAL REGISTRATION Trial registration number: ISRCTN29535824 . Date of registration: 28 May 2020. Retrospectively registered.
Collapse
Affiliation(s)
- Johan Gyllensvärd
- Department of Pediatrics, Region Jönköping County, Jönköping, Sweden S- 553 05, Jönköping, Sweden.
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Fredrik Ingemansson
- Department of Pediatrics, Region Jönköping County, Jönköping, Sweden S- 553 05, Jönköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Elisabet Hentz
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Studahl
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
23
|
Simeonova M, Piszczek J, Hoi S, Harder C, Pelligra G. Evaluation of compliance with the 2017 Canadian Paediatric Society Position Statement for the management of newborns at risk for early-onset sepsis: A retrospective cohort study. Paediatr Child Health 2020; 26:e152-e157. [PMID: 33936345 DOI: 10.1093/pch/pxaa042] [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: 10/09/2019] [Accepted: 02/26/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction Due to the nonspecific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Paediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management. Objective To examine the compliance with the CPS statement at a tertiary perinatal site and characterize the types of deviations. Methods A retrospective chart review was conducted for all term and late pre-term newborns at risk for sepsis, between January 1 and June 30, 2018. The prevalence of newborns with EOS risk factors was measured during the first month. Management strategies for eligible newborns during the 6-month period were compared to the CPS recommendations to establish the rate of noncompliance. The type of noncompliance, readmission rate, and rate of culture-positive EOS were examined. Results In the first month, 29% (66 of 228) of newborns had EOS risk factors. Among the 100 newborns born in the 6-month period for whom the CPS recommendations apply, 47 (47%) received noncompliant management. Of those, 51% (N=24) had inappropriately initiated investigations, 17% (N=8) had inappropriate antibiotics, and 32% (N=15) had both. The rate of readmission for a septic workup was 1.6% (N= 2). None had culture-positive sepsis while admitted. Conclusion A large proportion of term and late preterm newborns (29%) had EOS risk factors, but none had culture-confirmed EOS. The rate of noncompliance with the CPS recommendations was high (47%), mainly due to overzealous management. Future initiatives should aim at increasing compliance, particularly in newborns at lower EOS risk.
Collapse
Affiliation(s)
- Marina Simeonova
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Jolanta Piszczek
- Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia
| | - Sannifer Hoi
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Curtis Harder
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Gustavo Pelligra
- Department of Maternity Care and Pediatrics, Victoria General Hospital, Victoria, British Columbia.,Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
24
|
Berardi A, Bedetti L, Spada C, Lucaccioni L, Frymoyer A. Serial clinical observation for management of newborns at risk of early-onset sepsis. Curr Opin Pediatr 2020; 32:245-251. [PMID: 31851052 DOI: 10.1097/mop.0000000000000864] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Current management approaches for asymptomatic neonates at risk of early onset sepsis remain controversial. Strategies based entirely on clinical observation (SCO, serial clinical observation) have gained consensus. RECENT FINDINGS We briefly compare different strategies for managing asymptomatic newborns suggested in four high-income countries. Then this review details the existing differences in carrying out the SCO in the United Kingdom, the USA, and Italy; the experiences from the studies performed using the SCO; and open questions regarding this strategy. Advantages and limitations of SCO are also discussed. There is a need to assess which symptoms at birth are more predictive of early onset sepsis and therefore require immediate interventions versus those symptoms that can be monitored and re-evaluated. SUMMARY SCO strategy may require changes in the processes of newborn care at birthing centers. Nonetheless, SCO is safe and is associated with fewer laboratory evaluations and unnecessary antibiotics. Thoughtful and thorough practices related to the care of all newborns will benefit any birthing centre. VIDEO ABSTRACT: http://links.lww.com/MOP/A40.
Collapse
Affiliation(s)
- Alberto Berardi
- Neonatal Intensive Care Unit, Maternal and Child Department, University Hospital
| | - Luca Bedetti
- PhD Program in Clinical and Experimental Medicine, Maternal and Child Department
| | - Caterina Spada
- Pediatric Postgraduate School, Maternal and Child Department, University of Modena and Reggio Emilia, Italy
| | - Laura Lucaccioni
- Neonatal Intensive Care Unit, Maternal and Child Department, University Hospital
| | - Adam Frymoyer
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| |
Collapse
|
25
|
Santos JC, Reis J, Rangel MA, João A, Vinhas da Silva A. Management of newborns at increased risk for early-onset sepsis in perinatology department. J Matern Fetal Neonatal Med 2020; 35:161-165. [PMID: 32188315 DOI: 10.1080/14767058.2020.1714582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Assessing newborn infants at risk for early-onset sepsis (EOS) is a common clinical task conducted by pediatricians. A change in the internal protocol for managing neonates at risk was implemented in 2016. Unlike the previous protocol, which determined laboratory testing in asymptomatic newborns in the presence of one risk factor (RF) for sepsis; the new protocol advocates the screening in the presence of at least two RF. The purpose of this study was to characterize newborns at increased risk for EOS before and after the implementation of a diagnostic/treatment protocol.Methods: Retrospective analysis of asymptomatic newborns with RF to EOS who had laboratory testing performed at perinatology department in a central hospital in north of Portugal before and after the protocol was reviewed (2016), in the years 2015 and 2017, respectively. Patients were divided in two groups: preprotocol (2015) and postprotocol (2017), according to the date of admission.Results: A total of 361 newborns were enrolled, 296 (82%) pre-protocol and 65 (18%) post-protocol. There was a significant raise in the number of preterm newborns (9.5 versus 30.8%, pre- and post-protocol, respectively; p < .001), with similar other sociodemographic characteristics. There were 36 positive laboratory screenings at 12 h of life and 8.6% were transferred to the neonatology department, without differences between the groups (p = .250 and p = .488). All presented a favorable outcome, without differences in the number of readmissions in the first month of life (p = .204).Discussion: The modification of the approach protocol has led to a significant decline in the laboratory testing performed, minimizing newborn pain, unnecessary antibiotic exposure and costs, without increased risk of readmission for sepsis.
Collapse
Affiliation(s)
- Joana Caldeira Santos
- Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Joana Reis
- Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Maria Adriana Rangel
- Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - Anabela João
- Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| | - António Vinhas da Silva
- Department of Pediatrics, Centro Hospitalar de Vila Nova de Gaia Espinho EPE, Vila Nova de Gaia, Portugal
| |
Collapse
|
26
|
A Prospective Cohort Study of Factors Associated with Empiric Antibiotic De-escalation in Neonates Suspected with Early Onset Sepsis (EOS). Paediatr Drugs 2020; 22:321-330. [PMID: 32185682 PMCID: PMC7222079 DOI: 10.1007/s40272-020-00388-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Prolonged empiric antibiotic use, resulting from diagnostic uncertainties, in suspected early onset sepsis (EOS) cases constitutes a significant problem. Unnecessary antibiotic use increases the risk of antibiotic resistance. Furthermore, prolonged antibiotic use increases the risk of mortality and morbidity in neonates. Proactive measures including empiric antibiotic de-escalation are crucial to overcome these problems. METHODS This was a prospective cohort study conducted in the neonatal intensive care units of two public hospitals in Malaysia. Neonates with a gestational age greater than 34 weeks who were started on empiric antibiotics within 72 h of life were screened. The data were then stratified according to de-escalation and non-de-escalation practices, where de-escalation practice was defined as narrowing down or discontinuation of empiric antibiotic within 72 h of treatment. RESULTS A total of 1045 neonates were screened, and 429 were included. The neonates were then divided based on de-escalation (n = 207) and non-de-escalation (n = 222) practices. Neonates under non-de-escalation practices showed significantly longer durations of antibiotic use compared to those under de-escalation practices (p < 0.05), with no difference in treatment outcomes. Five factors were found to be associated with de-escalation of antibiotics. They are cesarean section delivery, exposure to antenatal steroids, nil history of maternal pyrexia, absence of meconium-stained amniotic fluid, and normal C-reactive protein ≤ 0.5 mg/dL (p < 0.05). CONCLUSIONS Empiric antibiotic de-escalation appears feasible as a routine form of treatment for EOS in late preterm and term neonates.
Collapse
|
27
|
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: 120] [Impact Index Per Article: 24.0] [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.
Collapse
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
| |
Collapse
|
28
|
Viel-Theriault I, Fell DB, Grynspan D, Redpath S, Thampi N. The transplacental passage of commonly used intrapartum antibiotics and its impact on the newborn management: A narrative review. Early Hum Dev 2019; 135:6-10. [PMID: 31177037 DOI: 10.1016/j.earlhumdev.2019.05.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 11/30/2022]
Abstract
Neonates exposed to intra-amniotic infection are at increased risk of early-onset sepsis. Administration of antibiotics to the mother may offer some protection, however a comprehensive description of the determinants influencing their transplacental passage and delivery to the fetus has not been performed. While penicillin G, ampicillin, cefazolin and gentamicin reach therapeutic levels in the fetal serum rapidly following maternal administration, the transfer of second-line intrapartum antimicrobials, such as vancomycin and clindamycin, is slower and less predictable. Erythromycin, used in the context of preterm premature rupture of the membranes, has suboptimal influx into the fetal compartment. This evidence is predominantly drawn from term pregnancies and situations of low infectious risk; however, prematurity may negatively influence fetal exposure to intrapartum antibiotics. Optimal fetal antimicrobial concentrations to target are poorly defined and the extent to which our review findings apply to preterm early-onset neonatal sepsis prevention is unclear. Interpretation of blood cultures drawn in neonates with expected circulating levels of maternal antimicrobials above the minimal inhibitory concentration for Group B Streptococcus is challenging despite the use of contemporary optimized blood culture media.
Collapse
Affiliation(s)
- I Viel-Theriault
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
| | - D B Fell
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - D Grynspan
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - S Redpath
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - N Thampi
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| |
Collapse
|
29
|
Sgro M, Kobylianskii A, Yudin MH, Tran D, Diamandakos J, Sgro J, Campbell DM. Population-based study of early-onset neonatal sepsis in Canada. Paediatr Child Health 2019; 24:e66-e73. [PMID: 30996609 PMCID: PMC6462127 DOI: 10.1093/pch/pxy018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the incidence, types of organisms and resistance patterns involved in early-onset neonatal sepsis in Canada. STUDY DESIGN Early-onset neonatal sepsis cases were identified through the Canadian Paediatric Surveillance Program. Neonates were excluded if they were asymptomatic or if intracranial procedures preceded a positive cerebrospinal fluid culture. RESULTS One hundred and twenty-seven cases were identified (0.17 cases per 1000 live births). Group B Streptococcus accounted for 41.7%, Escherichia coli for 35.4%. Antibiotic resistance was present in 33.9% of all cases. 55.6% of E coli cases were resistant, most commonly to ampicillin. Infecting organism species were associated with gestational age, being very low birth weight, time at sepsis presentation, maternal antibiotic prophylaxis and rupture of membranes lasting over 18 hours. Group B Streptococcus was most common in term and E coli in preterm neonates. Twenty-two per cent of E coli cases presented after 48 hours, compared to 6% of Group B Streptococcus cases. CONCLUSION We identify a lower rate of early-onset neonatal sepsis than historically suggested, with differing dominant organisms based on gestational ages and other factors, as well as high rates of resistance especially among E coli cases.
Collapse
Affiliation(s)
- Michael Sgro
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Paediatrics, St. Michael’s Hospital, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Anna Kobylianskii
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario
| | - Mark H Yudin
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario
- Department of Obstetrics and Gynaecology, St. Michael’s Hospital, Toronto, Ontario
| | - Dat Tran
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, Ontario
| | - Julia Diamandakos
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario
| | - Jonathan Sgro
- Department of Science, University of Western Ontario, London, Ontario
| | - Douglas M Campbell
- Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario
- Department of Paediatrics, St. Michael’s Hospital, Toronto, Ontario
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| |
Collapse
|
30
|
Le Saux N, Robinson J. Aminoglycosides-alive and well in treatment of pediatric infections: A case of benefit versus risk. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:1-5. [PMID: 36338783 PMCID: PMC9603187 DOI: 10.3138/jammi.2018.09.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 06/16/2023]
Affiliation(s)
- Nicole Le Saux
- University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Joan Robinson
- University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada
| |
Collapse
|
31
|
Clinical and Biochemical Effects of Recombinant Human Granulocyte Colony-Stimulating Factor on the Prognosis of Preterm Infants with Early Onset Neonatal Sepsis. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2019. [DOI: 10.5812/pedinfect.67807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
32
|
Lemyre B, Jefferies AL, O'Flaherty P. Facilitating discharge from hospital of the healthy term infant. Paediatr Child Health 2018; 23:515-531. [PMID: 30894791 DOI: 10.1093/pch/pxy127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This statement provides guidance for health care providers to ensure the safe discharge of healthy term infants who are born in hospital and who are ≥37 weeks' gestational age. Hospital care for mothers and infants should be family-centred, with healthy mothers and infants remaining together and going home at the same time. The specific length of stay for newborn infants depends on the health of their mother, infant health and stability, the mother's ability to care for her infant, support at home, and access to follow-up care. Many mother-infant dyads are ready to go home 24 h after birth. Parent or guardian education and assessment of discharge readiness are important components of discharge planning. Each infant must have an appropriate discharge plan, including identification of the infant's primary health care provider and assessment by a health care provider 24 h to 72 h after discharge.
Collapse
Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Ann L Jefferies
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Pat O'Flaherty
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| |
Collapse
|
33
|
Klingenberg C, Kornelisse RF, Buonocore G, Maier RF, Stocker M. Culture-Negative Early-Onset Neonatal Sepsis - At the Crossroad Between Efficient Sepsis Care and Antimicrobial Stewardship. Front Pediatr 2018; 6:285. [PMID: 30356671 PMCID: PMC6189301 DOI: 10.3389/fped.2018.00285] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/17/2018] [Indexed: 01/21/2023] Open
Abstract
Sepsis is a leading cause of mortality and morbidity in neonates. Presenting clinical symptoms are unspecific. Sensitivity and positive predictive value of biomarkers at onset of symptoms are suboptimal. Clinical suspicion therefore frequently leads to empirical antibiotic therapy in uninfected infants. The incidence of culture confirmed early-onset sepsis is rather low, around 0.4-0.8/1000 term infants in high-income countries. Six to 16 times more infants receive therapy for culture-negative sepsis in the absence of a positive blood culture. Thus, culture-negative sepsis contributes to high antibiotic consumption in neonatal units. Antibiotics may be life-saving for the few infants who are truly infected. However, overuse of broad-spectrum antibiotics increases colonization with antibiotic resistant bacteria. Antibiotic therapy also induces perturbations of the non-resilient early life microbiota with potentially long lasting negative impact on the individual's own health. Currently there is no uniform consensus definition for neonatal sepsis. This leads to variations in management. Two factors may reduce the number of culture-negative sepsis cases. First, obtaining adequate blood cultures (0.5-1 mL) at symptom onset is mandatory. Unless there is a strong clinical or biochemical indication to prolong antibiotics physician need to trust the culture results and to stop antibiotics for suspected sepsis within 36-48 h. Secondly, an international robust and pragmatic neonatal sepsis definition is urgently needed. Neonatal sepsis is a dynamic condition. Rigorous evaluation of clinical symptoms ("organ dysfunction") over 36-48 h in combination with appropriately selected biomarkers ("dysregulated host response") may be used to support or refute a sepsis diagnosis.
Collapse
Affiliation(s)
- Claus Klingenberg
- Pediatric Research Group, Faculty of Health Sciences, University of Tromsø-Arctic University of Norway, Tromsø, Norway.,Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - René F Kornelisse
- Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Buonocore
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Rolf F Maier
- Children's Hospital, University Hospital, Philipps University of Marburg, Marburg, Germany
| | - Martin Stocker
- Neonatal and Pediatric Intensive Care Unit, Children's Hospital, Lucerne, Switzerland
| |
Collapse
|
34
|
Fell DB, Hawken S, Wong CA, Wilson LA, Murphy MSQ, Chakraborty P, Lacaze-Masmonteil T, Potter BK, Wilson K. Using newborn screening analytes to identify cases of neonatal sepsis. Sci Rep 2017; 7:18020. [PMID: 29269842 PMCID: PMC5740154 DOI: 10.1038/s41598-017-18371-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/11/2017] [Indexed: 12/20/2022] Open
Abstract
Neonatal sepsis is associated with high mortality and morbidity, yet challenges with available diagnostic approaches can lead to delays in therapy. Our study assessed whether newborn screening analytes could be utilized to identify associations with neonatal sepsis. We linked a newborn screening registry with health databases to identify cases of sepsis among infants born in Ontario from 2010-2015. Correlations between sepsis and screening analytes were examined within three gestational age groups (early preterm: <34 weeks; late preterm: 34-36 weeks; term: ≥37 weeks), using multivariable logistic regression models. We started with a model containing only clinical factors, then added groups of screening analytes. Among 793,128 infants, 4,794 were diagnosed with sepsis during the neonatal period. Clinical variables alone or in combination with hemoglobin values were not strongly predictive of neonatal sepsis among infants born at term or late preterm. However, model fit improved considerably after adding markers of thyroid and adrenal function, acyl-carnitines, and amino acids. Among infants born at early preterm gestation, neither clinical variables alone nor models incorporating screening analytes adequately predicted neonatal sepsis. The combination of clinical variables and newborn screening analytes may have utility in identifying term or late preterm infants at risk for neonatal sepsis.
Collapse
Affiliation(s)
- Deshayne B Fell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), University of Ottawa, Ottawa Ontario, Canada
| | - Steven Hawken
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), University of Ottawa, Ottawa Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Coralie A Wong
- Institute for Clinical Evaluative Sciences (ICES), University of Ottawa, Ottawa Ontario, Canada
| | - Lindsay A Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Pranesh Chakraborty
- Department of Pediatrics, University of Ottawa, Ottawa Ontario, Canada.,Newborn Screening Ontario (NSO), Children's Hospital of Eastern Ontario, Ottawa Ontario, Canada
| | | | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa Ontario, Canada.,Institute for Clinical Evaluative Sciences (ICES), University of Ottawa, Ottawa Ontario, Canada
| | - Kumanan Wilson
- Institute for Clinical Evaluative Sciences (ICES), University of Ottawa, Ottawa Ontario, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Ontario, Canada. .,Department of Medicine, University of Ottawa, Ottawa Ontario, Canada.
| |
Collapse
|