1
|
Singu BS, Pieper CH, Verbeeck RK, Ette EI. Predictors of gentamicin therapy failure in neonates with sepsis. Pharmacol Res Perspect 2024; 12:e1250. [PMID: 39105353 DOI: 10.1002/prp2.1250] [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: 02/27/2024] [Revised: 06/15/2024] [Accepted: 07/04/2024] [Indexed: 08/07/2024] Open
Abstract
Sepsis is a common disease with high morbidity and mortality among newborns in intensive care units world-wide. Gram-negative bacillary bacteria are the major source of infection in neonates. Gentamicin is the most widely used aminoglycoside antibiotic in empiric therapy against early-onset sepsis. However, therapy failure may result due to various factors. The purpose of this study was to identify predictors of gentamicin therapy failure in neonates with sepsis. This was a prospective cross-sectional study at the Neonatal Intensive Care Unit at Windhoek Central Hospital over a period of 5 months in 2019. Neonates received intravenous gentamicin 5 mg/kg/24 h in combination with either benzylpenicillin 100 000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Logistic regression modeling was performed to determine the predictors of treatment outcomes. 36% of the 50 neonates were classified as having gentamicin treatment failure. Increasing treatment duration by 1 day resulted in odds of treatment failure increasing from 1.0 to 2.41. Similarly, one unit increase in CRP increases odds of gentamicin treatment failure by 49%. The 1 kg increase in birthweight reduces the log odds of treatment failure by 6.848, resulting in 99.9% decrease in the odds of treatment failure. One unit increase in WBC reduces odds of gentamicin treatment failure by 27%. Estimates of significant predictors of treatment failure were precise, yielding odds ratios that were within 95% confidence interval. This study identified the following as predictors of gentamicin therapy failure in neonates: prolonged duration of treatment, elevated C-reactive protein, low birthweight, and low white blood cell count.
Collapse
Affiliation(s)
| | | | - Roger Karel Verbeeck
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Ene I Ette
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| |
Collapse
|
2
|
Flannery DD, Zevallos Barboza A, Mukhopadhyay S, Gerber JS, McDonough M, Shu D, Hennessy S, Wade KC, Puopolo KM. Antibiotic use among extremely low birth-weight infants from 2009 to 2021: a retrospective observational study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326734. [PMID: 39033026 DOI: 10.1136/archdischild-2023-326734] [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: 12/08/2023] [Accepted: 06/20/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE To assess trends in antibiotic use across a large cohort of extremely low birth-weight (<1000 g; ELBW) infants admitted to academic and community neonatal intensive care units (NICUs) across the USA over a 13-year period. DESIGN Repeated cross-sectional cohort study. SETTING Premier Health Database, a comprehensive administrative database of inpatient encounters from academic and community hospitals across the US. PATIENTS ELBW inborn infants admitted to NICUs from 1 January 2009 to 31 December 2021. INTERVENTIONS N/A MAIN OUTCOME MEASURES: Absolute and relative changes in (1) proportion of ELBW infants with antibiotic exposure and (2) days of therapy (DOT) per 1000 patient days, over time. Average annual differences were estimated using generalised linear regression with 95% CI. Disposition trends were also measured. RESULTS Among 36 701 infants admitted to 402 NICUs, the proportion exposed to antibiotics was essentially unchanged (89.9% in 2009 to 89.3% in 2021; absolute reduction of -0.6%); generalised linear regression estimated an annual absolute difference of -0.3% (95% CI (-0.6%) to (-0.07%); p=0.01). DOT per 1000 patient days decreased from 337 in 2009 to 210 in 2021, a 37.8% relative difference and annual relative difference of -4.3% ((-5.2%) to (-3.5%); p<0.001). Mortality was unchanged during the study period. CONCLUSIONS We found a substantial reduction in antibiotic DOT despite no substantive change in the proportion of infants exposed to antibiotics. This suggests the success of stewardship efforts aimed at antibiotic duration and highlight the need for improved approaches to identifying ELBW infants at highest risk of infection.
Collapse
Affiliation(s)
- Dustin D Flannery
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sagori Mukhopadhyay
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly McDonough
- Center for Healthcare Quality & Analytics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Di Shu
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kelly C Wade
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen M Puopolo
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Mascarenhas D, Ho MSP, Ting J, Shah PS. Antimicrobial Stewardship Programs in Neonates: A Meta-Analysis. Pediatrics 2024; 153:e2023065091. [PMID: 38766702 DOI: 10.1542/peds.2023-065091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal sepsis is a significant contributor to mortality and morbidity; however, the uncontrolled use of antimicrobials is associated with significant adverse effects. Our objective with this article is to review the components of neonatal antimicrobial stewardship programs (ASP) and their effects on clinical outcomes, cost-effectiveness, and antimicrobial resistance. METHODS We selected randomized and nonrandomized trials and observational and quality improvement studies evaluating the impact of ASP with a cutoff date of May 22, 2023. The data sources for these studies included PubMed, Medline, Embase, Cochrane CENTRAL, Web of Science, and SCOPUS. Details of the ASP components and clinical outcomes were extracted into a predefined form. RESULTS Of the 4048 studies retrieved, 70 studies (44 cohort and 26 observational studies) of >350 000 neonates met the inclusion criteria. Moderate-certainty evidence reveals a significant reduction in antimicrobial initiation in NICU (pooled risk difference [RD] 19%; 95% confidence interval [CI] 14% to 24%; 21 studies, 27 075 infants) and combined NICU and postnatal ward settings (pooled RD 8%; 95% CI 6% to 10%; 12 studies, 358 317 infants), duration of antimicrobial agents therapy (pooled RD 20%; 95% CI 10% to 30%; 9 studies, 303 604 infants), length of therapy (pooled RD 1.82 days; 95% CI 1.09 to 2.56 days; 10 studies, 157 553 infants), and use of antimicrobial agents >5 days (pooled RD 9%; 95% CI 3% to 15%; 5 studies, 9412 infants). Low-certainty evidence reveals a reduction in economic burden and drug resistance, favorable sustainability metrices, without an increase in sepsis-related mortality or the reinitiation of antimicrobial agents. Studies had heterogeneity with significant variations in ASP interventions, population settings, and outcome definitions. CONCLUSIONS Moderate- to low-certainty evidence reveals that neonatal ASP interventions are associated with reduction in the initiation and duration of antimicrobial use, without an increase in adverse events.
Collapse
Affiliation(s)
- Dwayne Mascarenhas
- Neonatal-Perinatal Medicine Fellowship Training Program, University of Toronto, Toronto, Ontario
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
| | | | - Joseph Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Prakesh S Shah
- Department of Pediatrics, Sinai Health System, Toronto, Ontario
- Department of Pediatrics, University of Toronto, Ontario
| |
Collapse
|
4
|
Vidavalur R, Hussain N. Interstate Practice Variation and Factors Associated with Antibiotic Use for Suspected Neonatal Sepsis in the United States. Am J Perinatol 2024; 41:e1689-e1697. [PMID: 36963432 DOI: 10.1055/a-2061-8620] [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: 03/26/2023]
Abstract
OBJECTIVE This study aimed to estimate national time trends of overall and statewise antibiotic utilization (AU) rates for suspected neonatal sepsis (SNS) in the United States. STUDY DESIGN In this cross-sectional study, we used retrospective linked birth cohort and vital records data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database for the years 2016 to 2020 and analyzed data containing antibiotic use for SNS. The primary outcome was proportional national and state-specific AU rates per 1,000 live births during the birth hospitalization. Secondary outcomes included overall trends and association between maternal education, race, sex, chorioamnionitis, mode of delivery, gestational age at birth, Apgar's scores, and insurance status with antibiotics exposure for SNS among newborns. Contingency tables, two-tailed t-test, and chi-square for independence tests were performed with statistical significance set at p < 0.05. RESULTS For a birth cohort of >18 million, 2.2% of infants received antibiotics during birth hospitalization nationwide. There were wide variations in AU among U.S. states and territories, whereas overall treatment rates decreased by 16.1% (95% confidence interval [CI]: 15.2-17.0; p < 0.001). Compared with White newborns, Black newborns had higher AU rates (odds ratio [OR]: 1.33; 95% CI: 1.32-1.34), and Asians had the lowest rates (OR: 0.96; 95% CI: 0.95-0.97). There was a significant difference in mean AU rates by race (p < 0.001). Chorioamnionitis at birth significantly increased the odds for AU (OR: 14.5 ;95% CI: 14.4-14.6), although AU rates for chorioamnionitis showed a significant downward trend (OR: 0.52; 95% CI: 0.50-0.53) during the study period. CONCLUSION Our findings suggest that there has been a gradual decline in AU for SNS in more than a third of states in last 5 years. While risk-based management approaches achieve widespread implementation, state- and nationwide quality improvement collaborates might have contributed to the relative decline in antibiotic use in newborns. Further studies are warranted to understand factors related to practice variation in the management of SNS in the United States KEY POINTS: · Early and prolonged use of antibiotics can lead to altered gut microbiome and adverse long-term neonatal outcomes.. · There is considerable clinical practice variation in antibiotic-prescribing practices for suspected neonatal sepsis.. · This cross-sectional study reports the differences in neonatal antibiotic usage patterns by region and maternal factors.. · Antibiotic use should be limited to newborns at high risk of infection and proven sepsis.. · Judicious use of antibiotics can be promoted by following evidence-based approaches to sepsis risk assessment..
Collapse
Affiliation(s)
- Ramesh Vidavalur
- Division of Neonatology, Department of Pediatrics, Cayuga Medical Center/Weill Cornell Medicine, Ithaca, New York
| | - Naveed Hussain
- Division of Neonatology, Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
| |
Collapse
|
5
|
Singh HP, Wilkinson S, Kamran S. Decreasing Antibiotic Use in a Community Neonatal Intensive Care Unit: A Quality Improvement Initiative. Am J Perinatol 2024; 41:e2767-e2775. [PMID: 37607590 PMCID: PMC11150059 DOI: 10.1055/a-2158-8422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/16/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE In view of the excessive use of antibiotics in our neonatal intensive care unit (NICU), we launched a 5-year multidisciplinary quality improvement (QI) initiative in our NICU in 2018. We had set our aim of decreasing the antibiotic use rate (AUR) from 22 to 17%. STUDY DESIGN The QI initiative was conducted in our 53-bed level 3B NICU. We used the core elements of antibiotic stewardship and focused on improving gaps in knowledge by using updated standards of care and a multidisciplinary approach. Outcome measures included overall AUR in NICU. Statistical control chart (P chart) was used to plot the AUR data quarterly. RESULTS The AUR demonstrated a decline at the onset, and at the end of the initiative the AUR demonstrated a sustained decline to 13.18%, a 40% decrease from the baseline AUR of 22%. The changes that were implemented included development of evidence-based guidelines for babies less than and greater than 35 weeks, daily antibiotic stewardship rounds, sepsis risk calculator, antibiotic stop orders (48-hour stop, 36-hour soft stop, and 36-hour hard stop), and periodic reviews. CONCLUSION Our multidisciplinary approach using all the core elements of an antibiotic stewardship program significantly decreased AUR in our NICU. KEY POINTS · Excessive use of antibiotics may cause harm to the infant's health.. · Indiscriminate use of antibiotics can lead to antibiotic resistance.. · Stewardship programs can significantly decrease AUR in NICUs..
Collapse
Affiliation(s)
- Harjinder P. Singh
- Division of Neonatology, Pomona Valley Hospital Medical Center, Pomona, California
| | - Susan Wilkinson
- Division of Neonatology, Pomona Valley Hospital Medical Center, Pomona, California
| | - Shahid Kamran
- Division of Neonatology, Pomona Valley Hospital Medical Center, Pomona, California
| |
Collapse
|
6
|
Malviya MN, Murthi S, Selim AA, Malik F, Jayraj D, Mendoza J, Ramdas V, Rasheed S, Jabri AA, Sabri RA, Asiry SA, Yahmadi MA, Shah PS. A Neonatologist-Driven Antimicrobial Stewardship Program in a Neonatal Tertiary Care Center in Oman. Am J Perinatol 2024; 41:e747-e754. [PMID: 36037856 DOI: 10.1055/a-1933-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The overuse of antimicrobials in neonates is not uncommon and has resulted in a global health crisis of antibiotic resistance. This study aimed to evaluate changes associated with a neonatologist-driven antimicrobial stewardship program (ASP) in antibiotic usage. STUDY DESIGN We conducted a pre-post retrospective cohort study in a tertiary care hospital in Oman. Neonates admitted in 2014 to 2015 were considered as the pre-ASP cohort. In 2016, a neonatologist-driven ASP was launched in the unit. The program included the optimization and standardization of antibiotic use for early- and late-onset sepsis using the Centers for Disease Control and Prevention's "broad principles," an advanced antimicrobial decision-support system to resolve contentious issues, and placed greater emphasis on education and behavior modification. Data from the years 2016 to 2019 were compared with previous data. The outcome of interest included days of therapy (DOT) for antimicrobials. Baseline characteristics and outcomes were compared using standard statistical measures. RESULTS The study included 2,098 neonates in the pre-ASP period and 5,464 neonates in the post-ASP period. There was no difference in baseline characteristics. The antibiotic use decreased from 752 DOT per 1,000 patient-days (PD) in the pre-ASP period to 264 DOT in the post-ASP period (64.8% reduction, p < 0.001). The proportion of neonates who received any antibiotics declined by 46% (pre-ASP = 1,161/2,098, post-ASP = 1,676/5,464). The most statistically significant reduction in DOT per 1,000 PD was observed in the use of cefotaxime (82%), meropenem (74%), and piperacillin-tazobactam (74%). There was no change in mortality, culture-positive microbial profile, or multidrug-resistant organism incidence in the post-ASP period. CONCLUSION Empowering frontline neonatologists to drive ASPs was associated with a sustained reduction in antibiotic utilization. KEY POINTS · Overuse of antimicrobials is not uncommon in neonatal intensive care units.. · ASPs and infection control and prevention measures may help in decreasing antibiotic consumption and culture-positive sepsis.. · Empowering frontline neonatologists resulted in a sustained decrease in antimicrobial use without extra resources or financial burden..
Collapse
Affiliation(s)
| | | | - Ahmed A Selim
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Fadia Malik
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Dhanya Jayraj
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Julet Mendoza
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Vidhya Ramdas
- Department of Pediatrics, Khoula hospital, Muscat, Oman
| | - Sohail Rasheed
- Department of Information and Technology, Khoula hospital, Muscat, Oman
| | - Amal Al Jabri
- Department of Microbiology, Khoula hospital, Muscat, Oman
| | - Raid Al Sabri
- Department of Pharmacy, Khoula hospital, Muscat, Oman
| | | | | | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai hospital, Toronto, Canada
| |
Collapse
|
7
|
Barca HC, Ferber J, Richards M, Strickland M, Fernandez AJ, Li DK, Darrow LA. Antimicrobial exposure during infancy in a longitudinal California cohort. Pediatr Res 2024:10.1038/s41390-024-03171-x. [PMID: 38570559 DOI: 10.1038/s41390-024-03171-x] [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] [Received: 12/04/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND To describe temporal and sociodemographic patterns of antimicrobial exposure during the first year of life in a large US cohort. METHODS Singleton infants born 1998-2014 enrolled in Kaiser Permanente Northern California integrated health system (n = 345,550) were followed longitudinally via comprehensive electronic health records, capturing all systemic antimicrobial inpatient administrations and outpatient dispensings. Antimicrobial exposure was summarized by maternal and infant characteristics, birth year, inpatient/outpatient status, age in months, and drug class. RESULTS Overall, 44% of infants in this cohort received at least one dose of antimicrobials during infancy. Decreases over time were driven by reduced outpatient dispensings specifically in later infancy, primarily for penicillins. Among infants receiving any antimicrobials the median number of exposure-days was 16. Inpatient dispensings peaked in the first 30 days of life and outpatient dispensings peaked at 10-11 months. Birth characteristics (i.e., NICU admission, gestational age) were strong independent predictors of antimicrobial exposure between 0- < 3 months; sociodemographic factors were modest predictors of exposure for 3-12 months. CONCLUSION Predictors of antimicrobial exposure in early and late infancy are distinct with early infancy exposures highly correlated to birth characteristics. The cumulative proportion of infants exposed has decreased due to fewer late infancy outpatient dispensings. IMPACT Comprehensive antimicrobial exposure histories and the maternal and infant characteristics predicting exposure have not been well described in US populations. This analysis provides estimates of cumulative antimicrobial exposures by sociodemographic factors, delivery characteristics, month of life, inpatient/outpatient status, and antibiotic class among one of the largest US HMOs. Predictors of early infancy antimicrobial exposures differ from those in late infancy, with early exposures strongly correlated to birth characteristics and late infancy exposures modestly related to sociodemographic factors. Antimicrobial exposure among infants decreased over the time period primarily due to reduced outpatient dispensings in later infancy.
Collapse
Affiliation(s)
- Hannah C Barca
- School of Public Health, University of Nevada, Reno, Reno, NV, USA.
| | | | - Megan Richards
- School of Public Health, University of Nevada, Reno, Reno, NV, USA
| | | | | | - De-Kun Li
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Lyndsey A Darrow
- School of Public Health, University of Nevada, Reno, Reno, NV, USA
| |
Collapse
|
8
|
Torres-Muñoz J, Hoyos IV, Murillo J, Holguin J, Dávalos D, López E, Torres-Figueroa S. Device-associated infections in neonatal care units in a middle-income country, 2016-2018. J Pediatr (Rio J) 2023; 99:485-491. [PMID: 37148912 PMCID: PMC10492145 DOI: 10.1016/j.jped.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 05/08/2023] Open
Abstract
OBJECTIVE Describe the device-associated infections in the NICUs in Cali - Colombia, a middle-income country, between August 2016 to December 2018. METHODS Observational cross-sectional study evaluating reports of device-associated infections in 10 NICUs in Cali, Colombia, between August 2016 and December 2018. Socio-demographic and microbiological data were obtained from the National Public Health surveillance system, through a specialized notification sheet. The relationship of device-associated infections with several outcomes including birth weight, microorganisms, and mortality was evaluated using OR CI95%, using the logistic regression model. Data processing was performed using the statistical program STATA 16. RESULTS 226 device-associated infections were reported. The rate of infection with central line-associated bloodstream infections was 2.62 per 1000 days of device use and 2.32 per 1000 days for ventilator-associated pneumonia. This was higher in neonates under 1000 g; 4.59 and 4.10, respectively. 43.4% of the infections were due to gram-negative bacteria and 42.3% were due to gram-positive bacteria. Time from hospitalization to diagnosis of all device-associated infections had a median of 14 days. When compared by weight, infants with a weight lower than 1000 g had a greater chance of death (OR 3.61; 95% CI 1.53-8.49, p = 0.03). Infection by gram-negative bacteria was associated with a greater chance of dying (OR 3.06 CI 95 1.33-7.06, p = 0.008). CONCLUSIONS These results highlight the need to maintain epidemiological surveillance processes in neonatal intensive care units, especially when medical devices are used.
Collapse
Affiliation(s)
- Javier Torres-Muñoz
- Universidad del Valle, Faculty of Health, INSIDE Group Research-School of Medicine, Cali, Colombia; Universidad del Valle, Department of Pediatrics, Cali, Colombia.
| | - Ingrith Viviana Hoyos
- Universidad del Valle, Faculty of Health, INSIDE Group Research-School of Medicine, Cali, Colombia; Universidad del Valle, Department of Pediatrics, Cali, Colombia
| | - Jennifer Murillo
- Universidad del Valle, Faculty of Health, INSIDE Group Research-School of Medicine, Cali, Colombia
| | - Jorge Holguin
- Secretary of Health, Epidemiological Surveillance Group, Cali, Colombia
| | - Diana Dávalos
- Universidad Icesi, Department of Public Health, Cali, Colombia; Center for Studies in Pediatric Infectology, Cali, Colombia
| | - Eduardo López
- Universidad del Valle, Department of Pediatrics, Cali, Colombia; Center for Studies in Pediatric Infectology, Cali, Colombia; Imbanaco Clinic, Quironsalud Group, Cali, Colombia
| | | |
Collapse
|
9
|
Lewald ZS, Prusakov P, Magers JK, Kielt MJ, de Alba Romero C, White NO, Miller RR, Moraille R, Theile AR, Sánchez PJ. Short-course antibiotic therapy for pneumonia in the neonatal intensive care unit. J Perinatol 2023; 43:1145-1151. [PMID: 37438484 DOI: 10.1038/s41372-023-01720-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To determine the adherence and safety outcomes of a 5-day antibiotic course with a "time-out" for treatment of "blood culture-negative" pneumonia in the NICU. STUDY DESIGN Prospective surveillance of all infants diagnosed with pneumonia at 7 NICUs from 8/2020-12/2021. Safety outcomes were defined a priori by re-initiation of antibiotic therapy within 14 days after discontinuation and overall and sepsis-related mortality. RESULTS 128 infants were diagnosed with 136 episodes of pneumonia; 88% (n = 119) were treated with 5 days of definitive antibiotic therapy. Antibiotics were restarted within 14 days in 22 (16%) of the 136 pneumonia episodes. However, only 3 (3%) of the 119 episodes of pneumonia treated for 5 days had antibiotics restarted for pneumonia. Mortality was 5% (7/128); 5 of the 7 deaths were assessed as sepsis-related. CONCLUSION Adherence to the 5-day definitive antibiotic treatment for "culture-negative" pneumonia was high and the intervention seemed safe.
Collapse
Affiliation(s)
- Zachery S Lewald
- The Ohio State University, Columbus, OH, USA
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Pavel Prusakov
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Matthew J Kielt
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Concepción de Alba Romero
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | | | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| |
Collapse
|
10
|
Saturio S, Rey A, Samarra A, Collado MC, Suárez M, Mantecón L, Solís G, Gueimonde M, Arboleya S. Old Folks, Bad Boon: Antimicrobial Resistance in the Infant Gut Microbiome. Microorganisms 2023; 11:1907. [PMID: 37630467 PMCID: PMC10458625 DOI: 10.3390/microorganisms11081907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
The development of the intestinal microbiome in the neonate starts, mainly, at birth, when the infant receives its founding microbial inoculum from the mother. This microbiome contains genes conferring resistance to antibiotics since these are found in some of the microorganisms present in the intestine. Similarly to microbiota composition, the possession of antibiotic resistance genes is affected by different perinatal factors. Moreover, antibiotics are the most used drugs in early life, and the use of antibiotics in pediatrics covers a wide variety of possibilities and treatment options. The disruption in the early microbiota caused by antibiotics may be of great relevance, not just because it may limit colonization by beneficial microorganisms and increase that of potential pathogens, but also because it may increase the levels of antibiotic resistance genes. The increase in antibiotic-resistant microorganisms is one of the major public health threats that humanity has to face and, therefore, understanding the factors that determine the development of the resistome in early life is of relevance. Recent advancements in sequencing technologies have enabled the study of the microbiota and the resistome at unprecedent levels. These aspects are discussed in this review as well as some potential interventions aimed at reducing the possession of resistance genes.
Collapse
Affiliation(s)
- Silvia Saturio
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
| | - Alejandra Rey
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
| | - Anna Samarra
- Institute of Agrochemistry and Food Technology (IATA-CSIC), 46980 Paterna, Spain; (A.S.); (M.C.C.)
| | - Maria Carmen Collado
- Institute of Agrochemistry and Food Technology (IATA-CSIC), 46980 Paterna, Spain; (A.S.); (M.C.C.)
| | - Marta Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Laura Mantecón
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Gonzalo Solís
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Miguel Gueimonde
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
| | - Silvia Arboleya
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
| |
Collapse
|
11
|
Pace E, Yanowitz TD, Waltz P, Morowitz MJ. Antibiotic therapy and necrotizing enterocolitis. Semin Pediatr Surg 2023; 32:151308. [PMID: 37295297 DOI: 10.1016/j.sempedsurg.2023.151308] [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: 06/12/2023]
Abstract
Antibiotic therapy remains a cornerstone of treatment of both medical and surgical presentations of necrotizing enterocolitis (NEC). However, guidelines regarding the administration of antibiotics for the treatment of NEC are lacking and practices vary amongst clinicians. Although the pathogenesis of NEC is unknown, there is consensus that the infant gastrointestinal microbiome contributes to the disease. The presumed connection between dysbiosis and NEC has prompted some to study whether early prophylactic enteral antibiotics can prevent NEC. Yet others have taken an opposing approach, studying whether perinatal antibiotic exposure increases the risk of NEC by inducing a state of dysbiosis. This narrative review summarizes what is known about antibiotics and their association with the infant microbiome and NEC, current antibiotic prescribing practices for infants with medical and surgical NEC, as well as potential strategies to further optimize the use of antibiotics in this population of infants.
Collapse
Affiliation(s)
- Elizabeth Pace
- University of Pittsburgh Department of Surgery, United States
| | - Toby D Yanowitz
- University of Pittsburgh Department of Pediatrics, Division of Neonatology, United States
| | - Paul Waltz
- University of Pittsburgh Department of Surgery, Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, United States
| | - Michael J Morowitz
- University of Pittsburgh Department of Surgery, Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, United States.
| |
Collapse
|
12
|
Perez K, Puia-Dumitrescu M, Comstock BA, Wood TR, Mayock DE, Heagerty PJ, Juul SE. Patterns of Infections among Extremely Preterm Infants. J Clin Med 2023; 12:2703. [PMID: 37048786 PMCID: PMC10095151 DOI: 10.3390/jcm12072703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/30/2023] [Accepted: 04/02/2023] [Indexed: 04/08/2023] Open
Abstract
Infections remain a leading cause of neonatal death, especially among the extremely preterm infants. To evaluate the incidence, pathogenesis, and in-hospital outcomes associated with sepsis among hospitalized extremely preterm infants born at 24-0/7 to 27-6/7 weeks of gestation, we designed a post hoc analysis of data collected prospectively during the Preterm Epo Neuroprotection (PENUT) Trial, NCT #01378273. We analyzed culture positive infection data, as well as type and duration of antibiotic course and described their association with in-hospital morbidities and mortality. Of 936 included infants, 229 (24%) had at least one positive blood culture during their hospitalization. Early onset sepsis (EOS, ≤3 days after birth) occurred in 6% of the infants, with Coagulase negative Staphylococci (CoNS) and Escherichia Coli the most frequent pathogens. Late onset sepsis (LOS, >day 3) occurred in 20% of the infants. Nearly all infants were treated with antibiotics for presumed sepsis at least once during their hospitalization. The risk of confirmed or presumed EOS was lower with increasing birthweight. Confirmed EOS had no significant association with in-hospital outcomes or death while LOS was associated with increased risk of necrotizing enterocolitis and death. Extremely premature infants with presumed sepsis as compared to culture positive sepsis had lower rates of morbidities. In conclusion, the use of antibiotics for presumed sepsis remains much higher than confirmed infection rates. Ongoing work exploring antibiotic stewardship and presumed, culture-negative sepsis in extremely preterm infants is needed.
Collapse
Affiliation(s)
- Krystle Perez
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
| | | |
Collapse
|
13
|
França A. The Role of Coagulase-Negative Staphylococci Biofilms on Late-Onset Sepsis: Current Challenges and Emerging Diagnostics and Therapies. Antibiotics (Basel) 2023; 12:antibiotics12030554. [PMID: 36978421 PMCID: PMC10044083 DOI: 10.3390/antibiotics12030554] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/24/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023] Open
Abstract
Infections are one of the most significant complications of neonates, especially those born preterm, with sepsis as one of the principal causes of mortality. Coagulase-negative staphylococci (CoNS), a group of staphylococcal species that naturally inhabit healthy human skin and mucosa, are the most common cause of late-onset sepsis, especially in preterms. One of the risk factors for the development of CoNS infections is the presence of implanted biomedical devices, which are frequently used for medications and/or nutrient delivery, as they serve as a scaffold for biofilm formation. The major concerns related to CoNS infections have to do with the increasing resistance to multiple antibiotics observed among this bacterial group and biofilm cells’ increased tolerance to antibiotics. As such, the treatment of CoNS biofilm-associated infections with antibiotics is increasingly challenging and considering that antibiotics remain the primary form of treatment, this issue will likely persist in upcoming years. For that reason, the development of innovative and efficient therapeutic measures is of utmost importance. This narrative review assesses the current challenges and emerging diagnostic tools and therapies for the treatment of CoNS biofilm-associated infections, with a special focus on late-onset sepsis.
Collapse
Affiliation(s)
- Angela França
- Centre of Biological Engineering, LIBRO—Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal;
- LABBELS—Associate Laboratory in Biotechnology and Bioengineering and Microelectromechanical Systems, Braga and Guimarães, Portugal
| |
Collapse
|
14
|
Baltogianni M, Giapros V, Kosmeri C. Antibiotic Resistance and Biofilm Infections in the NICUs and Methods to Combat It. Antibiotics (Basel) 2023; 12:antibiotics12020352. [PMID: 36830264 PMCID: PMC9951928 DOI: 10.3390/antibiotics12020352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Neonatal sepsis is an important cause of neonatal morbidity and mortality. A significant proportion of bacteria causing neonatal sepsis is resistant to multiple antibiotics, not only to the usual empirical first-line regimens, but also to second- and third-line antibiotics in many neonatal intensive care units (NICUs). NICUs have unique antimicrobial stewardship goals. Apart from antimicrobial resistance, NICUs have to deal with another problem, namely biofilm infections, since neonates often have central and peripheral lines, tracheal tubes and other foreign bodies for a prolonged duration. The aim of this review is to describe traditional and novel ways to fight antibiotic-resistant bacteria and biofilm infections in NICUs. The topics discussed will include prevention and control of the spread of infection in NICUs, as well as the wise use of antimicrobial therapy and ways to fight biofilm infections.
Collapse
Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-26-5100-7546
| | - Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 45500 Ioannina, Greece
| |
Collapse
|
15
|
Hou S, Wang X, Yu Y, Ji H, Dong X, Li J, Li H, He H, Li Z, Yang Z, Chen W, Yao G, Zhang Y, Zhang J, Bi M, Niu S, Zhao G, Zhu R, Liu G, Jia Y, Gao Y. Invasive fungal infection is associated with antibiotic exposure in preterm infants: a multi-centre prospective case-control study. J Hosp Infect 2023; 134:43-49. [PMID: 36646139 DOI: 10.1016/j.jhin.2023.01.002] [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: 11/07/2022] [Revised: 12/31/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Previous antibiotic exposure is an important risk factor for invasive fungal infection (IFI). Antibiotic overexposure is common in lower-income countries; however, multi-centre studies concerning IFI in relation to antibiotic exposure are scarce. AIM This prospective, multi-centre matched case-control study explored the correlation of IFI and antibiotic exposure in very preterm infants or very-low-birthweight infants admitted to 23 tertiary hospitals in China between 2018 and 2021. METHODS Using a 1:2 matched design for gestational age, birth weight and early-onset sepsis (yes/no), the risk factors between infants diagnosed with IFI and infection-free controls were compared. The antibiotic use rate (AUR) was calculated using calendar days of antibiotic therapy in the 4 weeks preceding IFI onset divided by onset day of IFI. FINDINGS In total, 6368 infants were included in the study, of which 90 (1.4%) were diagnosed with IFI. Median AUR, length of antibiotic therapy (LOT) and days of antibiotic therapy (DOT) within the 4 weeks preceding IFI onset were 0.90, 18 days and 30 days, respectively. Multi-variate analysis showed that a 10% increase in AUR, each additional day of DOT and LOT, and each additional day of third-generation cephalosporins and carbapenems were notably associated with IFI. CONCLUSION Prolonged antibiotic therapy is common before the onset of IFI, and is an important risk factor, especially the use of third-generation cephalosporins and carbapenems. Antibiotic stewardship should be urgently developed and promoted for preterm infants in order to reduce IFI in lower-income countries such as China.
Collapse
Affiliation(s)
- S Hou
- Department of Paediatrics, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - X Wang
- Department of Paediatrics, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Y Yu
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China; Department of Neonatology, Shandong Provincial Hospital, Shandong University, Jinan, China.
| | - H Ji
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China; Department of Neonatology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - X Dong
- Department of Neonatology, Shandong Provincial Maternal and Child Health Hospital, Jinan, Shandong, China
| | - J Li
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - H Li
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - H He
- Department of Neonatology, Baogang Third Hospital of Hongci Group, Baotou, Inner Mongolia, China
| | - Z Li
- Department of Neonatology, W.F. Maternal and Child Health Hospital, Weifang, China
| | - Z Yang
- Department of Neonatology, Taian Maternal and Child Health Care Hospital, Taian, Shandong, China
| | - W Chen
- Department of Neonatology, People's Hospital of Rizhao, Rizhao, China
| | - G Yao
- Department of Neonatology, The Affiliated Taian City Central Hospital of Qingdao University, Taian, Shandong, China
| | - Y Zhang
- Department of Neonatology, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - J Zhang
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, China
| | - M Bi
- Department of Neonatology, Jinan Central Hospital, Jinan, China
| | - S Niu
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, China
| | - G Zhao
- Department of Neonatology, Binzhou Medical University Hospital, Binzhou, China
| | - R Zhu
- Department of Neonatology, Zibo Municipal Hospital, Zibo, China
| | - G Liu
- Department of Neonatology, Yidu Central Hospital of Weifang, Weifang, China
| | - Y Jia
- Department of Neonatology, Shanxi Province Shangluo Central Hospital, Shanluo, China
| | - Y Gao
- Department of Neonatology, Qilu Hospital of Shandong University Dezhou Hospital, Shanluo, China
| |
Collapse
|
16
|
Feng K, He Y, Liu W, Zhang X, Song P, Hua Z. Evaluation of antibiotic stewardship among near-term and term infants admitted to a neonatal unit. Eur J Pediatr 2023; 182:245-254. [PMID: 36289096 DOI: 10.1007/s00431-022-04668-5] [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: 04/26/2022] [Revised: 09/30/2022] [Accepted: 10/15/2022] [Indexed: 01/12/2023]
Abstract
UNLABELLED To evaluate the safety and effectiveness of evidence-based antibiotic stewardship in a neonatal unit in China. The study period consisted of two phases, one retrospective (the baseline period, January to December 2018, and the transition period, January 2019 to August 2020) and one prospective intervention period (September 2020 to August 2021). During the prospective period, evidence-based antibiotic stewardship was applied to neonates with suspected infections, pneumonia, and culture-negative sepsis. The antibiotic stewardship included the observation form of neonatal infections, antibiotic therapy of no more than 48 h for suspected infections, and 5 days for pneumonia and culture-negative sepsis. The change in antibiotic use measured by days of therapy per 1000 patient-days between the baseline and intervention period was analyzed. Safety outcomes included reinitiation of antibiotics within 14 days, length of stay, occurrence of late-onset sepsis and necrotizing enterocolitis (Bell stage ≥ II), multidrug-resistant organism infections, and mortality. A total of 7705 neonates were enrolled during the baseline (n = 4804) and the intervention periods (n = 2901). The total antibiotic usage during the baseline period was 771 days of therapy per 1000 patient-days, while that was 525 days of therapy per 1000 patient-days during the intervention period, indicating a 32% decrease in antibiotic consumption. No significant difference in safety outcomes was observed between the baseline and intervention period (P > 0.05), whereas the length of stay was longer during the intervention period (P < 0.001). CONCLUSION The evidence-based antibiotic stewardship can safely and effectively reduce antibiotic use and shorten the duration of therapy in the neonatal unit. WHAT IS KNOWN • Overuse of antibiotics has been associated with adverse events in neonates, including necrotizing enterocolitis, multidrug-resistant organism infections, and death. • More clinical effectiveness evidence is needed to support antibiotic stewardship of neonates in China. WHAT IS NEW • Using prospective audit, targeted stewardship interventions, this study shows that a 32% reduction in overall antibiotic consumption was achieved safely. • Implementation of evidence-based neonatal antibiotic stewardship, including the observation form of neonatal infections, antibiotic therapy of no more than 48 h for suspected infections, and 5 days for pneumonia and culture-negative sepsis, is safe and effective among newborns in a developing country.
Collapse
Affiliation(s)
- Kun Feng
- Department of Neonatology, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, No. 136 Zhongshan Er Rd, Yuzhong District, Chongqing, 400014, China
| | - Yunyan He
- Department of Neonatology, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, No. 136 Zhongshan Er Rd, Yuzhong District, Chongqing, 400014, China
| | - Weiqin Liu
- Department of Neonatology, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, No. 136 Zhongshan Er Rd, Yuzhong District, Chongqing, 400014, China
| | - Xinyin Zhang
- Department of Neonatology, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, No. 136 Zhongshan Er Rd, Yuzhong District, Chongqing, 400014, China
| | - Ping Song
- Children's Medical Big Data Intelligent Application, Chongqing University Engineering Research Center, Chongqing, 400014, China
| | - Ziyu Hua
- Department of Neonatology, Children's Hospital of Chongqing Medical University/Ministry of Education Key Laboratory of Child Development and Disorders/National Clinical Research Center for Child Health and Disorders/China International Science and Technology Cooperation Base of Child Development and Critical Disorders/Chongqing Key Laboratory of Pediatrics, No. 136 Zhongshan Er Rd, Yuzhong District, Chongqing, 400014, China.
| |
Collapse
|
17
|
Mukhopadhyay S, Briker SM, Flannery DD, Dhudasia MB, Coggins SA, Woodford E, Walsh EM, Li S, Puopolo KM, Kuzniewicz MW. Time to positivity of blood cultures in neonatal late-onset bacteraemia. Arch Dis Child Fetal Neonatal Ed 2022; 107:583-588. [PMID: 35273079 PMCID: PMC9465986 DOI: 10.1136/archdischild-2021-323416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/21/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the time to positivity (TTP) of blood cultures among infants with late-onset bacteraemia and predictors of TTP >36 hours. DESIGN Retrospective cohort study. SETTING 16 birth centres in two healthcare systems. PATIENTS Infants with positive blood cultures obtained >72 hours after birth. OUTCOME The main outcome was TTP, defined as the time interval from specimen collection to when a neonatal provider was notified of culture growth. TTP analysis was restricted to the first positive culture per infant. Patient-specific and infection-specific factors were analysed for association with TTP >36 hours. RESULTS Of 10 235 blood cultures obtained from 3808 infants, 1082 (10.6%) were positive. Restricting to bacterial pathogens and the first positive culture, the median TTP (25th-75th percentile) for 428 cultures was 23.5 hours (18.4-29.9); 364 (85.0%) resulted in 36 hours. Excluding coagulase-negative staphylococci (CoNS), 275 of 294 (93.5%) cultures were flagged positive by 36 hours. In a multivariable model, CoNS isolation and antibiotic pretreatment were significantly associated with increased odds of TTP >36 hours. Projecting a 36-hour empiric duration at one site and assuming that all negative evaluations were associated with an empiric course of antibiotics, we estimated that 1164 doses of antibiotics would be avoided in 629 infants over 10 years, while delaying a subsequent antibiotic dose in 13 infants with bacteraemia. CONCLUSIONS Empiric antibiotic administration in late-onset infection evaluations (not targeting CoNS) can be stopped at 36 hours. Longer durations (48 hours) should be considered when there is pretreatment or antibiotic therapy is directed at CoNS.
Collapse
Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara M Briker
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dustin D Flannery
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Miren B Dhudasia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Emily Woodford
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eileen M Walsh
- Division of Research, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Sherian Li
- Division of Research, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael W Kuzniewicz
- Division of Research, Kaiser Permanente Northern California, San Francisco, California, USA
- Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California, USA
| |
Collapse
|
18
|
Kounnavong S, Yan W, Sihavong A, Sychareun V, Eriksen J, Hanson C, Chaleunvong K, Keohavong B, Vongsouvath M, Mayxay M, Brauner A, Stålsby Lundborg C, Machowska A. Antibiotic knowledge, attitudes and reported practice during pregnancy and six months after birth: a follow- up study in Lao PDR. BMC Pregnancy Childbirth 2022; 22:701. [PMID: 36096811 PMCID: PMC9465860 DOI: 10.1186/s12884-022-05018-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background Antibiotics are important medicines to prevent maternal and child morbidity and mortality. Women’s knowledge and attitudes towards antibiotic use influence their practice. When they become mothers, this may be mirrored in the use of antibiotics for their newborn children. The current study aimed to assess knowledge, attitudes, and reported practice of pregnant women regarding antibiotic use and antibiotic resistance as well as their approach towards antibiotic use for their newborn babies. Methods This was a follow-up study with data collected via structured interviews between September 2019 and August 2020 in Feuang (rural) and Vangvieng (urban) districts in Vientiane province, Lao PDR. We identified and invited all women attending antenatal care in their third trimester of pregnancy in the selected areas. Using a structured questionnaire at third trimester of pregnancy we captured data on knowledge regarding antibiotic use and resistance. We collected information on attitudes and reported practice at two time points: (i) at third trimester of pregnancy and (ii) 6 months after birth. Univariate analysis and frequency distributions were used to study pattern of responses. Chi-square and Mann-Whitney tests were used to compare categorical and continuous variables respectively. P value < 0.05 was considered statistically significant. Results We surveyed 539 women with a mean age of 25 years. Two oral antibiotics, i) ampicillin and ii) amoxicillin were correctly identified by 68 and 47% of participants respectively. Only 24% of women (19% in Feuang and 29% in Vangvieng) answered correctly that antibiotics are effective against bacterial infections. The most prevalent response was “I don’t know” suggesting the questions were challenging. Significantly less women would use antibiotics from a previous illness for their child than for themselves (16% vs 29%), however they would be more willing to use antibiotics for their baby even in case of mild symptoms (29% vs 17% while pregnant). The majority of antibiotics were prescribed by healthcare providers and 46% of children with the common cold received antibiotics. Conclusions Women’s knowledge was sub-optimal, still, they manifested appropriate attitudes towards antibiotic use during pregnancy and for their child. Nearly half of children received antibiotics for the common cold. There is a need for context adapted programs aiming at improving women’s knowledge, as well as healthcare providers, emphasising rational antibiotic prescribing during pregnancy and for children.
Collapse
Affiliation(s)
- Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane, Lao PDR
| | - Weirong Yan
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Amphoy Sihavong
- Vientiane Capital Health Department, Ministry of Health, Vientiane, Lao PDR
| | | | - Jaran Eriksen
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases/Venhalsan, Stockholm South General Hospital, Stockholm, Sweden
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kongmany Chaleunvong
- Institute of Research and Education Development, University of Health Sciences, Vientiane, Lao PDR
| | | | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Welcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR
| | - Mayfong Mayxay
- Lao-Oxford-Mahosot Hospital-Welcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.,Institute of Research and Education Development, UHS, Ministry of Health, Vientiane, Lao PDR.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Annelie Brauner
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden.,Division of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Machowska
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
19
|
Viel-Thériault I, Agarwal A, Bariciak E, Le Saux N, Thampi N. Antimicrobial Prophylaxis Use in the Neonatal Intensive Care Unit: An Antimicrobial Stewardship Target That Deserves Attention! Am J Perinatol 2022; 39:1288-1291. [PMID: 33454950 DOI: 10.1055/s-0040-1722600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Previous analyses of neonatal intensive care units (NICU) antimicrobial stewardship programs have identified key contributors to overall antibiotic use, including prolonged empiric therapy >48 hours for early-onset sepsis (EOS). However, most were performed in mixed NICU settings with onsite birthing units, resulting in a high proportion of inborn patient admissions. The study aimed to describe and analyze the most common reasons for antimicrobial use in an outborn tertiary care NICU. STUDY DESIGN This was a 10-month review of all antimicrobial doses prescribed in a 20-bed level III NICU. The primary outcome was the total days of therapy (DOT) and length of therapy (LOT) for each clinical indication. Secondary outcomes included total DOT for each antimicrobial and appropriateness of antimicrobial courses. RESULTS Of 235 antibiotic courses and 1,899 DOT (519 DOT/1,000 patient days) prescribed in 173 infants during the study period, the most common indications were suspected EOS, followed by prophylaxis. Among the 85 DOT/1,000 patient days (PD; 38 courses) prescribed for prophylaxis, 52.5 DOT/1,000 PD (25 courses; 62%) were for surgical prophylaxis. Of 17 postoperative antibiotic courses, 15 (88.2%) were deemed to be inappropriate mostly due to a duration greater than 24 hours postoperatively (n = 13; median LOT = 3 days). CONCLUSION Surgical prophylaxis is a common reason for antimicrobial misuse in outborn NICU. NICU-based prospective audit and feedback between neonatologists and antimicrobial stewardship teams alone may not be impactful in this setting. Partnerships with neonatologists and surgeons will be key to achieving the target of less than 24 hours of postoperative antimicrobials. KEY POINTS · Surgical prophylaxis is a common reason for antimicrobial misuse in the NICU.. · Antimicrobial prophylaxis duration of less than 24 hours postoperatively should be encouraged.. · NICU-based prospective audit and feedback may not be impactful unless surgeons are involved..
Collapse
Affiliation(s)
- Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, Centre Hospitalier de l'Université Laval, Québec, Québec, Canada
| | - Amisha Agarwal
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Erika Bariciak
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nisha Thampi
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| |
Collapse
|
20
|
Alriyami A, Kiger JR, Hooven TA. Ventilator-Associated Pneumonia in the Neonatal Intensive Care Unit. Neoreviews 2022; 23:e448-e461. [PMID: 35773508 DOI: 10.1542/neo.23-7-e448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
See Bonus NeoBriefs videos and downloadable teaching slides Intubated infants in the NICU are at risk of developing ventilator-associated pneumonia (VAP), a common type of health care-associated infection. The Centers for Disease Control and Prevention developed guidelines for diagnosing VAP in patients younger than 1 year, which include worsening gas exchange, radiographic findings, and at least 3 defined clinical signs of pneumonia. VAP in infants is treated with empiric antibiotics selected based on local resistance patterns and individualized patient data. Many NICUs have implemented prevention bundles in an effort to decrease VAP by ensuring the cleanest environment for intubated neonates (hand hygiene, sterile handling of equipment), positioning of infants to prevent gastric reflux, and constantly reevaluating for extubation readiness. Although these prevention bundle elements are intuitive and generally low risk, none are based on strong research support. This article reviews the epidemiology, pathogenesis, diagnosis, treatment, and prevention of VAP in NICU patients, focusing on recent evidence, highlighting areas of emerging research, and identifying persistent knowledge gaps.
Collapse
Affiliation(s)
- Ayesha Alriyami
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - James R Kiger
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas A Hooven
- Division of Newborn Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Richard King Mellon Institute for Pediatric Research, Pittsburgh, PA
| |
Collapse
|
21
|
Thänert R, Sawhney SS, Schwartz DJ, Dantas G. The resistance within: Antibiotic disruption of the gut microbiome and resistome dynamics in infancy. Cell Host Microbe 2022; 30:675-683. [PMID: 35550670 PMCID: PMC9173668 DOI: 10.1016/j.chom.2022.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/28/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Abstract
Intestinal host-microbiota interactions during the first year of life are critical for infant development. Early-life antibiotic exposures disrupt stereotypical gut microbiota maturation and adversely affect childhood health. Furthermore, antibiotics increase the abundance of resistant bacteria and enrich the resistome-the compendium of antibiotic resistance genes-within the gut microbiota. Here, we discuss acute and persistent impacts of antibiotic exposure during infancy on pediatric health, the gut microbiome, and, particularly, the resistome. Reviewing our current understanding of antibiotic resistance acquisition and dissemination within and between microbiomes, we highlight open questions, which are imperative to resolve in the face of rising bacterial resistance.
Collapse
Affiliation(s)
- Robert Thänert
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Sanjam S Sawhney
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Drew J Schwartz
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO, USA; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA.
| |
Collapse
|
22
|
Hou S, Wang X, Wang F, Li Z, Wang H, Li J, Wang J, He H, Deng L, Feng Y, Fan X, Li W, Lu Q, Ma Y, Zhao G, Reddy S, Wu Y, Yu Y. Excessively Prolonged Early Antibiotic Duration in Very-Low-Birth-Weight Infants: A Multicenter Prospective Cohort Study in a Developing Country. Infect Drug Resist 2022; 15:1921-1931. [PMID: 35469306 PMCID: PMC9034863 DOI: 10.2147/idr.s349478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/16/2022] [Indexed: 01/17/2023] Open
Abstract
Purpose Significant antibiotic overuse due to prolonged antibiotic duration has not draw enough attention in developing countries with high antibiotic consumption. We aimed to describe the current status of prolonged early antibiotic duration in very-low-birth-weight (VLBW) infants in a large regional multicenter cohort in China. Patients and Methods Institution-based prospective cohort study was conducted in all VLBW infants admitted to 16 Grade A tertiary hospitals between January 1, 2019 and December 31, 2020. Early antibiotic use was defined as antibiotic initiation within the first 3 days of life. Prolonged early antibiotic course was defined as early antibiotic initiation for more than 7 days in infants with early-onset sepsis (EOS) or more than 3 days in infants with unlikely EOS. Antibiotic use was described as days of therapy (DOT) per 1000 patient days (PD). Results Among 1684 eligible VLBW infants, 1544 (91.7%) infants were prescribed with prolonged early antibiotic course, including 618 infants with EOS and 926 infants with unlikely EOS. The median duration of early antibiotic course was 13 (IQR 8;20) days, with 78.0% of courses >7 days and 43.6% of courses >14 days. Total early antibiotic use was 408.3DOT/1000Pd, of which prolonged antibiotic courses accounted for 98.2% of all antibiotic use days. More than three antibiotics used, escalation antibiotic therapy, antibiotics for special use and the use of third generation cephalosporins and carbapenems were significantly common in prolonged courses compared to short courses in both infants with EOS and unlikely EOS group (P<0.05). Conclusion A large proportion of VLBW infants had excessively prolonged early antibiotic durations in the regional multicenter in China. Timely discontinuation of antibiotics in VLBW infants according to standardized guidelines and limit on the use of third-generation cephalosporins and carbapenems may be key drivers in reducing the antibiotic overuse in developing countries like ours.
Collapse
Affiliation(s)
- Shanshan Hou
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, People’s Republic of China
- Department of Pediatric, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, People’s Republic of China
| | - Xiaokang Wang
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, People’s Republic of China
| | - Fang Wang
- Department of Neonatology, Liaocheng People’s Hospital, Liaocheng, 252000, People’s Republic of China
| | - Zhongliang Li
- Department of Neonatology, W.F. Maternal and Child Health Hospital, Weifang, 261011, People’s Republic of China
| | - Hui Wang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, 065000, People’s Republic of China
| | - Jiahui Li
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, People’s Republic of China
| | - Jing Wang
- Department of Neonatology, Women and Children’s Healthcare Hospital of Linyi, Linyi, 276000, People’s Republic of China
| | - Haiying He
- Department of Neonatology, Baogang Third Hospital of Hongci Group, Baotou, 014010, People’s Republic of China
| | - Liping Deng
- Department of Neonatology, Heze Municipal Hospital, Heze, 274031, People’s Republic of China
| | - Yushu Feng
- Department of Neonatology, Linyi People’s Hospital, Linyi, 276000, People’s Republic of China
| | - Xiufang Fan
- Department of Neonatology, Jinan Maternity and Child Health Care Hospital, Jinan, 250001, People’s Republic of China
| | - Wen Li
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, 250012, People’s Republic of China
| | - Qinghua Lu
- Department of Neonatology, Shandong Maternal and Child Health Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250014, People’s Republic of China
| | - Yanying Ma
- Department of Neonatology, Jinan Second Maternal and Child Health Care Hospital, Jinan, 271100, People’s Republic of China
| | - Guoying Zhao
- Department of Neonatology, Binzhou Medical University Hospital, Binzhou, 256603, People’s Republic of China
| | - Simmy Reddy
- Cheeloo College of Medicine, Shandong University, Jinan, 250021, People’s Republic of China
| | - Yanqiu Wu
- Department of Pediatric, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, People’s Republic of China
- Yanqiu Wu, Department of Pediatric, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, No. 20, Yuhuangding East Road, Zhi fu District, Yantai, 264000, People’s Republic of China, Tel +86-0535-6691999, Email
| | - Yonghui Yu
- Department of Neonatology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, People’s Republic of China
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, People’s Republic of China
- Correspondence: Yonghui Yu, Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 234, Jingwu, Road, Huai Yin District, Jinan, Shandong, 250021, People’s Republic of China, Tel +86-0531-66953201, Email ;
| |
Collapse
|
23
|
Kopsidas I, Molocha NM, Kourkouni E, Coffin S, Gkentzi D, Chorianopoulou E, Dimitriou G, Kapetanaki A, Karavana G, Lithoxopoulou M, Polychronaki M, Roilides E, Triantafyllidou P, Triantafyllou C, Tsopela GC, Tsouvala E, Tsolia MN, Zaoutis T, Spyridis N. Potential benefit from the implementation of the Kaiser Permanente neonatal early-onset sepsis calculator on clinical management of neonates with presumed sepsis. Eur J Pediatr 2022; 181:1001-1008. [PMID: 34664107 DOI: 10.1007/s00431-021-04282-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
To assess the potential benefit from the implementation of the Kaiser Permanente early-onset sepsis calculator (EOS-C), in terms of antibiotic use and requested laboratory tests, in a network of neonatal intensive care units (NICUs) in Greece, and to determine the incidence of early-onset sepsis (EOS) in Greek NICUs, a prospective surveillance study was conducted in 7 NICUs between April 2018 and June 2019. Data were collected for all newborns ≥ 34 weeks' gestation receiving empiric antibiotic therapy within the first 3 days of life. The number of live births and positive blood or cerebrospinal fluid cultures within the first 3 days of life were used for calculation of EOS incidence. Evaluation of possible impact of implementing the calculator was done by comparing the clinicians' recorded management to the calculator's suggested course of action. The unit-specific incidence of culture-proven EOS ranged between 0 and 2.99/1000 live births. The weighted incidence rate for all 7 units was 1.8/1000 live births. Management of EOS guided by the calculator could lead to a reduction of empiric antibiotic initiation up to 100% for the group of "well-appearing" neonates and 86% for "equivocal," lowering exposure to antibiotics by 4.2 and 3.8 days per neonate, respectively. Laboratory tests for blood cultures drawn could be reduced by up to 100% and 68%, respectively. Sensitivity of the EOS-C in identifying neonates with positive blood cultures was high.Conclusion: Management strategies based on the Kaiser Permanente neonatal sepsis calculator may significantly reduce antibiotic exposure, invasive diagnostic procedures, and hospitalizations in late preterm and term neonates. What is Known: • Neonates are frequently exposed to antibiotics for presumed EOS. • The Kaiser Permanente sepsis calculator can reduce antibiotic exposure in neonates.. What is New: • EOS calculator can be an effective antibiotic stewardship tool in a high prescribing country and can reduce invasive diagnostic procedures and mother-baby separation. • Incidence of EOS in Greece is higher compared to other European countries.
Collapse
Affiliation(s)
- Ioannis Kopsidas
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece.,Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece
| | | | - Eleni Kourkouni
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Susan Coffin
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Despoina Gkentzi
- Department of Pediatrics, University General Hospital of Patras, Patras Medical School, Patras, Greece
| | | | - Gabriel Dimitriou
- Department of Pediatrics, University General Hospital of Patras, Patras Medical School, Patras, Greece
| | - Anastasia Kapetanaki
- Neonatal Intensive Care Unit, Elenas Venizelou Maternity Hospital, Athens, Greece
| | - Georgia Karavana
- Neonatal Intensive Care Unit, General Hospital of Nikaia and Piraeus "Aghios Panteleimon", Athens, Greece
| | - Maria Lithoxopoulou
- Second Department of Neonatology, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Emmanuel Roilides
- Third Department of Pediatrics, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | - Emmanouela Tsouvala
- Neonatal Intensive Care Unit, General University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Maria N Tsolia
- Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece
| | - Theoklis Zaoutis
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece.,Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Nikos Spyridis
- Second Department of Pediatrics, National and Kapodistrian, University of Athens, School of Medicine, Athens, Greece.
| | | |
Collapse
|
24
|
Look Who's Talking: Host and Pathogen Drivers of Staphylococcus epidermidis Virulence in Neonatal Sepsis. Int J Mol Sci 2022; 23:ijms23020860. [PMID: 35055041 PMCID: PMC8775791 DOI: 10.3390/ijms23020860] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 02/04/2023] Open
Abstract
Preterm infants are at increased risk for invasive neonatal bacterial infections. S. epidermidis, a ubiquitous skin commensal, is a major cause of late-onset neonatal sepsis, particularly in high-resource settings. The vulnerability of preterm infants to serious bacterial infections is commonly attributed to their distinct and developing immune system. While developmentally immature immune defences play a large role in facilitating bacterial invasion, this fails to explain why only a subset of infants develop infections with low-virulence organisms when exposed to similar risk factors in the neonatal ICU. Experimental research has explored potential virulence mechanisms contributing to the pathogenic shift of commensal S. epidermidis strains. Furthermore, comparative genomics studies have yielded insights into the emergence and spread of nosocomial S. epidermidis strains, and their genetic and functional characteristics implicated in invasive disease in neonates. These studies have highlighted the multifactorial nature of S. epidermidis traits relating to pathogenicity and commensalism. In this review, we discuss the known host and pathogen drivers of S. epidermidis virulence in neonatal sepsis and provide future perspectives to close the gap in our understanding of S. epidermidis as a cause of neonatal morbidity and mortality.
Collapse
|
25
|
Tiozzo C, Mukhopadhyay S. Noninfectious influencers of early-onset sepsis biomarkers. Pediatr Res 2022; 91:425-431. [PMID: 34802035 PMCID: PMC8818022 DOI: 10.1038/s41390-021-01861-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 01/21/2023]
Abstract
Diagnostic tests for sepsis aim to either detect the infectious agent (such as microbiological cultures) or detect host markers that commonly change in response to an infection (such as C-reactive protein). The latter category of tests has advantages compared to culture-based methods, including a quick turnaround time and in some cases lower requirements for blood samples. They also provide information on the immune response of the host, a critical determinant of clinical outcome. However, they do not always differentiate nonspecific host inflammation from true infection and can inadvertently lead to antibiotic overuse. Multiple noninfectious conditions unique to neonates in the first days after birth can lead to inflammatory marker profiles that mimic those seen among infected infants. Our goal was to review noninfectious conditions and patient characteristics that alter host inflammatory markers commonly used for the diagnosis of early-onset sepsis. Recognizing these conditions can focus the use of biomarkers on patients most likely to benefit while avoiding scenarios that promote false positives. We highlight approaches that may improve biomarker performance and emphasize the need to use patient outcomes, in addition to conventional diagnostic performance analysis, to establish clinical utility.
Collapse
Affiliation(s)
- Caterina Tiozzo
- Division of Neonatology, Department of Pediatrics, New York University, Langone Health, New York City, New York, United States
| | - Sagori Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| |
Collapse
|
26
|
Mundal HS, Rønnestad A, Klingenberg C, Stensvold HJ, Størdal K. Antibiotic Use in Term and Near-Term Newborns. Pediatrics 2021; 148:183440. [PMID: 34814187 DOI: 10.1542/peds.2021-051339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We aimed to study whether national and local antibiotic stewardship projects have reduced the antibiotic use in newborns and to monitor potential changes in adverse outcomes. METHODS In a nationwide, population-based study from Norway, we included all hospital live births from 34 weeks' gestation (n = 282 046) during 2015 to 2019. The primary outcome was the proportion of newborns treated with antibiotics from 0 to 28 days after birth. The secondary outcomes were the overall duration of antibiotic treatment and by categories: culture-positive sepsis, clinical sepsis, and no sepsis. RESULTS A total of 7365 (2.6%) newborns received intravenous antibiotics during the period, with a reduction from 3.1% in 2015 to 2.2% in 2019 (30% decrease; P < .001). Hospitals with antibiotic stewardship projects experienced the largest reduction (48% vs 23%; P < .001). We found a small decrease in the median duration of antibiotic treatment in newborns without sepsis from 2.93 to 2.66 days (P = .011), and geographical variation was reduced during the study period. The overall number of days with antibiotic treatments was reduced by 37% from 2015 to 2019 (119.1 of 1000 vs 75.6 of 1000; P < .001). Sepsis was confirmed by blood culture in 206 newborns (incidence rate: 0.73 cases per 1000 live births). We found no increase in sepsis with treatment onset >72 hours of life, and sepsis-attributable deaths remained at a low level. CONCLUSIONS During the study period, a substantial decrease in the proportion of newborns treated with antibiotics was observed together with a decline in treatment duration for newborns without culture-positive sepsis.
Collapse
Affiliation(s)
| | - Arild Rønnestad
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø-The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Hans Jørgen Stensvold
- NICU, Clinic of Pediatric and Adolescent Medicine.,Neonatal Clinical and Epidemiological Research Group, Oslo University Hospital, Oslo, Norway
| | - Ketil Størdal
- NICU, Clinic of Pediatric and Adolescent Medicine.,Pediatric Research Institute, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
27
|
Jiang S, Zhang L, Yan W, Li S, Han J, Zhou Q, Yang Y, Lee SK, Cao Y. Antibiotic Use in Neonatal Intensive Care Units in China: A Multicenter Cohort Study. J Pediatr 2021; 239:136-142.e4. [PMID: 34461063 DOI: 10.1016/j.jpeds.2021.08.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/21/2021] [Accepted: 08/10/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To provide national-level antibiotic use data from Chinese neonatal intensive care units to inform future antimicrobial stewardship using a large contemporary cohort of preterm infants in China. STUDY DESIGN This retrospective cohort study enrolled all infants less than 340/7 weeks of gestation admitted to 25 tertiary neonatal intensive care units across China between May 1, 2015, and April 30, 2018. The antibiotic use rate (AUR) was defined as the number of days an infant was prescribed with 1 or more antibiotics divided by the total length of hospital stay. RESULTS Among 24 597 eligible infants, 21 736 (88.4%) infants received antibiotics. The median AUR was 441 per 1000 patient-days (IQR, 242-692 per 1000 patient-days). The median duration of each antibiotic course was 9 days (IQR, 6-14 days). Overall, 64.6% infants received broad-spectrum antibiotics, with a median broad-spectrum AUR of 250 per 1000 patient-days (IQR, 0-500 per 1000 patient-days), accounting for 70.7% of all antibiotic use days. Overall, 68.7% of all antibiotic use occurred among infants without infection-related morbidities, with a median duration of 8 days (IQR, 6-13 days) for each course. Only 22.9% episodes of culture-negative sepsis were prescribed with antibiotics for 7 or fewer days, and 34.7% were treated with antibiotics for more than 14 days. For early antibiotic use, the median duration of antibiotic therapy within 7 days after birth was 7 days (IQR, 4-7 days). CONCLUSIONS A high AUR among infants without infections, prolonged antibiotic durations, and excessive use of broad-spectrum antibiotics were the main problems of antibiotic use in Chinese neonatal intensive care units and should be high-impact focuses for future stewardship interventions.
Collapse
Affiliation(s)
- Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Lan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Weili Yan
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Shujuan Li
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Junyan Han
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Qi Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yi Yang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
| | | |
Collapse
|
28
|
Woodford EC, Dhudasia MB, Puopolo KM, Skerritt LA, Bhavsar M, DeLuca J, Mukhopadhyay S. Neonatal blood culture inoculant volume: feasibility and challenges. Pediatr Res 2021; 90:1086-1092. [PMID: 33824451 PMCID: PMC8492767 DOI: 10.1038/s41390-021-01484-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Clinicians often express concerns about poor sensitivity of blood cultures in neonates resulting from inadequate inoculant volumes. Our objective was to determine the inoculant volume sent for neonatal sepsis evaluations and identify areas of improvement. METHODS Single-center prospective observational study of infants undergoing sepsis evaluation. Blood volume was determined by clinician documentation over 21 months, and additionally by weighing culture bottles during 12 months. Adequate volume was defined as ≥1 mL total inoculant per evaluation. For first-time evaluations, local guidelines recommend sending an aerobic-anaerobic pair with 1 mL inoculant in each. RESULTS There were 987 evaluations in 788 infants. Clinicians reported ≥1 mL total inoculant in 96.9% evaluations. Among 544 evaluations where bottles were weighed, 93.4% had ≥1 mL total inoculant. Very low birth weight infants undergoing evaluations >7 days after birth had the highest proportion of inadequate inoculants (14.4%). Only 3/544 evaluations and 26/1011 bottles had total inoculant <0.5 mL. Ninety evaluations had <1 mL in both aerobic and anaerobic bottles despite a total inoculant volume that allowed inoculation of ≥1 mL in one of the bottles. CONCLUSIONS Obtaining recommended inoculant volumes is feasible in majority of neonates. Measuring inoculant volumes can focus improvement efforts and improve test reliability. IMPACT Clinicians express concern about the unreliability of neonatal blood cultures because of inadequate inoculant volume. We investigated over 900 evaluations and found >90% of evaluations have ≥1 mL inoculant. Monitoring adequacy of blood culture technique can identify areas of improvement and may allay concerns about blood culture reliability. Current recommendations for adequate inoculant volume for blood cultures are met in a majority of neonates. Areas of improvement include preterm late-onset sepsis evaluations and distribution techniques during inoculation.
Collapse
Affiliation(s)
- Emily C Woodford
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Miren B Dhudasia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | | | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
29
|
Wang HC, Tsai MH, Chu SM, Liao CC, Lai MY, Huang HR, Chiang MC, Fu RH, Hsu JF. Clinical characteristics and outcomes of neonates with polymicrobial ventilator-associated pneumonia in the intensive care unit. BMC Infect Dis 2021; 21:965. [PMID: 34535089 PMCID: PMC8446475 DOI: 10.1186/s12879-021-06673-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Ventilator associated pneumonia (VAP) caused by more than one microorganisms is not uncommon and may be potentially challenging, but the relevant data is scarce in ventilated neonates. We aimed to investigate the clinical characteristics and outcomes of polymicrobial VAP in the neonatal intensive care unit (NICU). METHODS All neonates with definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and September 2020 were prospectively observed and enrolled for analyses. All clinical features, therapeutic interventions and outcomes were compared between the polymicrobial VAP and monomicrobial VAP episodes. Multivariate regression analyses were used to find the independent risk factors for treatment failure. RESULTS Among 236 episodes of neonatal VAP, 60 (25.4%) were caused by more than one microorganisms. Polymicrobial VAP episodes were more likely to be associated with multidrug-resistant pathogens (53.3% versus 34.7%, P = 0.014), more often occurred in later days of life and in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. Otherwise most clinical characteristics of polymicrobial VAP were similar to those of monomicrobial VAP. The therapeutic responses and treatment outcomes were also comparable between these two groups, although modification of therapeutic antibiotics were significantly more common in polymicrobial VAP episodes than monomicrobial VAP episodes (63.3% versus 46.2%; P < 0.001). None of any specific pathogens was significantly associated with worse outcomes. Instead, it is the severity of illness, including presence of concurrent bacteremia, septic shock, and requirement of high-frequency oscillatory ventilator and underlying neurological sequelae that are independently associated with treatment failure. CONCLUSIONS Polymicrobial VAP accounted for 25.4% of all neonatal VAP in the NICU, and frequently occurred in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. In our cohort, most clinical features, therapeutic responses and final outcomes of neonates with monomicrobial and polymicrobial VAP did not differ significantly.
Collapse
Affiliation(s)
- Hsiao-Chin Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Chu Liao
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, No. 5, Fu-Shin Rd., Kwei Shan, Taoyuan County, 333, Linkou, Taiwan, ROC.
| |
Collapse
|
30
|
Mukhopadhyay S, Puopolo KM, Hansen NI, Lorch SA, DeMauro SB, Greenberg RG, Cotten CM, Sánchez PJ, Bell EF, Eichenwald EC, Stoll BJ. Neurodevelopmental outcomes following neonatal late-onset sepsis and blood culture-negative conditions. Arch Dis Child Fetal Neonatal Ed 2021; 106:467-473. [PMID: 33478957 PMCID: PMC8292446 DOI: 10.1136/archdischild-2020-320664] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Determine risk of death or neurodevelopmental impairment (NDI) in infants with late-onset sepsis (LOS) versus late-onset, antibiotic-treated, blood culture-negative conditions (LOCNC). DESIGN Retrospective cohort study. SETTING 24 neonatal centres. PATIENTS Infants born 1/1/2006-31/12/2014, at 22-26 weeks gestation, with birth weight 401-1000 g and surviving >7 days were included. Infants with early-onset sepsis, necrotising enterocolitis, intestinal perforation or both LOS and LOCNC were excluded. EXPOSURES LOS and LOCNC were defined as antibiotic administration for ≥5 days with and without a positive blood/cerebrospinal fluid culture, respectively. Infants with these diagnoses were also compared with infants with neither condition. OUTCOMES Death or NDI was assessed at 18-26 months corrected age follow-up. Modified Poisson regression models were used to estimate relative risks adjusting for covariates occurring ≤7 days of age. RESULTS Of 7354 eligible infants, 3940 met inclusion criteria: 786 (20%) with LOS, 1601 (41%) with LOCNC and 1553 (39%) with neither. Infants with LOS had higher adjusted relative risk (95% CI) for death/NDI (1.14 (1.05 to 1.25)) and death before follow-up (1.71 (1.44 to 2.03)) than those with LOCNC. Among survivors, risk for NDI did not differ between the two groups (0.99 (0.86 to 1.13)) but was higher for LOCNC infants (1.17 (1.04 to 1.31)) compared with unaffected infants. CONCLUSIONS Infants with LOS had higher risk of death, but not NDI, compared with infants with LOCNC. Surviving infants with LOCNC had higher risk of NDI compared with unaffected infants. Improving outcomes for infants with LOCNC requires study of the underlying conditions and the potential impact of antibiotic exposure.
Collapse
Affiliation(s)
- Sagori Mukhopadhyay
- Pediatrics, Neonatology, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nellie I. Hansen
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC, USA
| | - Scott A. Lorch
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B. DeMauro
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Pablo J. Sánchez
- Neonatology and Pediatric Infectious Diseases, Nationwide Children’s Hospital, The Ohio State University College of Medicine, The Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Eric C. Eichenwald
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Barbara J. Stoll
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | |
Collapse
|
31
|
Villanueva P, Freyne B, Hickey L, Carr J, Bryant PA. Impact of an antimicrobial stewardship intervention in neonatal intensive care: Recommendations and implementation. J Paediatr Child Health 2021; 57:1208-1214. [PMID: 33729615 DOI: 10.1111/jpc.15427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 02/17/2021] [Indexed: 12/18/2022]
Abstract
AIM To (i) determine the appropriateness of antimicrobial prescribing in the neonatal intensive care unit (NICU) and (ii) assess the impact of a collaborative antimicrobial stewardship (AMS) intervention on prescribing practices. METHODS The intervention was a weekly AMS audit-feedback joint ward round (6-month period) of Neonatology and Infectious Diseases clinicians in a tertiary neonatal intensive care unit in Melbourne, Australia. Antibiotic prescriptions were audited and recommendations delivered in real time. The proportion of recommendations implemented was used to assess acceptability of the intervention. RESULTS During the study period, there were 23 AMS rounds, during which 249 patients were reviewed at 627 separate episodes. Of these, 233 (37%) episodes were for patients receiving antimicrobials. Of these, 147 (63%) received empirical antimicrobial treatment, 43 (18%) targeted antimicrobial treatment and 43 (18%) antimicrobial prophylaxis. There were 58 (25%) of 233 episodes of inappropriate antibiotic use, and 62 recommendations for improvement. Most common recommendations were to narrow (33/62, 53%) or stop (12/62, 19%) antimicrobials. The majority (45, 73%) of recommendations were accepted, resulting in significant improvement in the proportion of the 233 episodes that had completely appropriate antibiotic prescribing: 175 (75%) to 217 (93%) (relative risk 1.2, 95% confidence intervals 1.1-1.3, P < 0.001). CONCLUSIONS A collaborative audit-feedback AMS intervention was effective in identifying inappropriate antimicrobial prescriptions and impacted positively on treatment plans. Ancillary benefits were improved communication between departments and the revision of antimicrobial prescribing guidelines.
Collapse
Affiliation(s)
- Paola Villanueva
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Bridget Freyne
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Leah Hickey
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neonatal Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Carr
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
32
|
Jansen SJ, Lopriore E, Beek MT, Veldkamp KE, Steggerda SJ, Bekker V. The road to zero nosocomial infections in neonates-a narrative review. Acta Paediatr 2021; 110:2326-2335. [PMID: 33955065 PMCID: PMC8359829 DOI: 10.1111/apa.15886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/08/2021] [Accepted: 04/22/2021] [Indexed: 12/11/2022]
Abstract
Aim Nosocomial infections (NI) in neonates are associated with prolonged hospitalisation, adverse neurodevelopmental outcome and high mortality. Over the past decade, numerous prevention strategies have resulted in significant reductions in NI rates. In this review, we aim to provide an overview of current NI rates from large, geographically defined cohorts. Methods PubMed, Web of Science, EMBASE and Cochrane Library were searched for evidence regarding epidemiology and prevention of NI in neonates. Extracted studies were synthesised in a narrative form with experiential reflection. Results Despite the abundance of geographically defined incidence proportions, an epidemiological overview of NI is difficult to provide, given the lack of consensus definition for neonatal NI and different baseline populations being compared. Successful prevention efforts have focused on implementing evidence‐based practices while eliminating outdated strategies. The most promising model for reduction in infection rates is based on quality improvement (QI) collaboratives and benchmarking, involving identification and implementation of best practices, selection of measurable outcomes and fostering a sense of community and transparency. Conclusion The preventative rather than curative approach forms the new paradigm for reducing the burden of neonatal infections. Despite progress achieved, continued work towards improved prevention practices is required in the strive towards zero NIs.
Collapse
Affiliation(s)
- Sophie J. Jansen
- Division of Neonatology Department of Pediatrics Willem Alexander Children's Hospital – Leiden University Medical Center (LUMC) Leiden The Netherlands
| | - Enrico Lopriore
- Division of Neonatology Department of Pediatrics Willem Alexander Children's Hospital – Leiden University Medical Center (LUMC) Leiden The Netherlands
| | - Martha T. Beek
- Department of Medical Microbiology Leiden University Medical Center (LUMC Leiden The Netherlands
| | - Karin Ellen Veldkamp
- Department of Medical Microbiology Leiden University Medical Center (LUMC Leiden The Netherlands
| | - Sylke J. Steggerda
- Division of Neonatology Department of Pediatrics Willem Alexander Children's Hospital – Leiden University Medical Center (LUMC) Leiden The Netherlands
| | - Vincent Bekker
- Division of Neonatology Department of Pediatrics Willem Alexander Children's Hospital – Leiden University Medical Center (LUMC) Leiden The Netherlands
| |
Collapse
|
33
|
Cussen A, Guinness L. Cost savings from use of a neonatal sepsis calculator in Australia: A modelled economic analysis. J Paediatr Child Health 2021; 57:1037-1043. [PMID: 33592674 DOI: 10.1111/jpc.15384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 01/25/2023]
Abstract
AIM To estimate the change in average cost and length of stay (LOS) for the neonatal birth admission resulting from use of the neonatal early-onset sepsis (EOS) calculator compared to guideline-based management, in an Australian perinatal health-care setting. METHODS A decision-analytic model (decision tree) was constructed to assess admission cost and LOS with EOS calculator use compared to guideline-based management. Probabilities of clinical sepsis-related outcomes were obtained via review of published literature. Costs and average LOS were obtained from Australia's Independent Hospital Pricing Authority. RESULTS EOS calculator use was associated with a reduction in costs of AUD$25806 and in average LOS of 25.4 days per 1000 babies born. Sensitivity analyses demonstrated greater net benefits could be expected for services where there is a higher baseline rate of antibiotic use. CONCLUSION This model demonstrates a significant cost reduction for the neonatal birth admission, associated with use of the EOS calculator as compared to existing guidelines. The net benefit may be greater in Australia, where rates of empiric antibiotic use are reportedly high, compared to some European countries and the United States. Future research opportunities include prospective collection of economic data alongside the introduction of the EOS calculator.
Collapse
Affiliation(s)
- Alexandra Cussen
- Department of Paediatrics, Austin Health, Heidelberg, Victoria, Australia
| | - Lorna Guinness
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
34
|
Abstract
Neonatal sepsis is a major cause of morbidity and mortality in neonates and is challenging to diagnose. Infants manifest nonspecific clinical signs in response to sepsis; these signs may be caused by noninfectious conditions. Time to antibiotics affects neonatal sepsis outcome, so clinicians need to identify and treat neonates with sepsis expeditiously. Clinicians use serum biomarkers to measure inflammation and infection and assess the infant's risk of sepsis. However, current biomarkers lack sufficient sensitivity or specificity to be consider useful diagnostic tools. Continued research to identify novel biomarkers as well as novel ways of measuring them is sorely needed.
Collapse
Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Division of Allergy, Immunology, and Infectious Diseases, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - John H Lee
- Department of Pediatrics, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| |
Collapse
|
35
|
Microbial Contamination in Hospital Environment Has the Potential to Colonize Preterm Newborns' Nasal Cavities. Pathogens 2021; 10:pathogens10050615. [PMID: 34067889 PMCID: PMC8156200 DOI: 10.3390/pathogens10050615] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/29/2021] [Accepted: 05/14/2021] [Indexed: 12/13/2022] Open
Abstract
Infants born before 28 weeks are at risk of contracting healthcare-associated infections (HAIs), which could be caused by pathogens residing on contaminated hospital surfaces. In this longitudinal study, we characterized by NGS the bacterial composition of nasal swabs of preterm newborns, at the time of birth and after admission to the Neonatal Intensive Care Unit (NICU), comparing it with that of the environmental wards at the time of delivery and during the hospitalization. We characterized the resistome on the samples too. The results showed that environmental microorganisms responsible for HAIs, in particular Staphylococcus spp., Streptococcus spp., Escherichia-Shigella spp., and K. pneumoniae, were detected in higher percentages in the noses of the babies after 13 days of hospitalization, in terms of the number of colonized patients, microorganism amount, and relative abundance. The analysis of nasal bacteria resistome evidenced the absence of resistance genes at the time of birth, some of which appeared and increased after the admission in the NICU. These data suggest that hospital surface microbiota might be transported to respiratory mucosae or other profound tissues. Our study highlights the importance of a screening that allows characterizing the microbial profile of the environment to assess the risk of colonization of the newborn.
Collapse
|
36
|
Korang SK, Safi S, Nava C, Gordon A, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013837. [PMID: 33998666 PMCID: PMC8127574 DOI: 10.1002/14651858.cd013837.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Possibly due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units. The last Cochrane Review was updated in 2004. Given the clinical importance, an updated systematic review assessing the effects of different antibiotic regimens for early-onset neonatal sepsis is needed. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for early-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2020, Issue 8); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for early-onset neonatal sepsis. We included participants from birth to 72 hours of life at randomisation. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (865 participants). All trials were at high risk of bias. The certainty of the evidence according to GRADE was very low. The included trials assessed five different comparisons of antibiotics. We did not conduct any meta-analyses due to lack of relevant data. Of the five included trials one trial compared ampicillin plus gentamicin with benzylpenicillin plus gentamicin; one trial compared piperacillin plus tazobactam with amikacin; one trial compared ticarcillin plus clavulanic acid with piperacillin plus gentamicin; one trial compared piperacillin with ampicillin plus amikacin; and one trial compared ceftazidime with benzylpenicillin plus gentamicin. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. Large RCTs assessing different antibiotic regimens in early-onset neonatal sepsis with low risk of bias are warranted.
Collapse
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Adrienne Gordon
- Neonatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
37
|
Sridharan K, Al Jufairi M, Qader AM, Elsegai OAM. Dose Optimization of Gentamicin in Critically Ill Neonates. Curr Drug Metab 2021; 21:270-280. [PMID: 32394828 DOI: 10.2174/1389200221666200512111131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Appropriate dosing of gentamicin in critically ill neonates is still debated. OBJECTIVE To assess the peak concentration (Cmax) and area-under-the-time-concentration curve (AUC0-24) of gentamicin and to simulate the recommended doses using the Monte Carlo method. METHODS This was a retrospective study on critically ill neonates carried over a one-year period. The demographic characteristics, dosage regimen and gentamicin concentrations were recorded for each neonate. Using Bayesian pharmacokinetic modeling, Cmax and AUC0-24 were predicted. Dose recommendations for the target Cmax (μg/ml) of 12 were obtained, and Monte Carlo simulation (100,000 iterations) was used for predicting the pharmacokinetic parameters and recommended doses for various birth weight categories. RESULTS Eighty-two critically ill neonates (with an average gestational age of 33.7 weeks; and birth weight of 2.1 kg) were recruited. Higher Cmax and AUC0-24 values were predicted in premature neonates, with greater cumulative AUCs in extremely preterm neonates. The average administered dose was 4 mg/kg/day and 75% of the participants had Cmax greater than 12 μg/ml following a single dose, and 85% were found to be at steady state. On the contrary, only 25% of the study population had the recommended AUC0-24 (above 125 μg-hr/ml). Simulation tests indicate that 90% of the critically ill neonates would achieve recommended Cmax with doses ranging between 5 and 6 mg/kg/day. CONCLUSION Currently used dose of 4 mg/kg/day is adequate to maintain Cmax in a large majority of the study population, with one-fourth population reporting the recommended AUC0-24. Increasing the dose to 5-6 mg/kg/day will more likely help to achieve both the recommended Cmax and AUC0-24 values.
Collapse
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Muna Al Jufairi
- Department of Pediatrics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain.,Neonatal Intensive Care Unit, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
| | - Ali Mohamed Qader
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Ola A M Elsegai
- Department of Pathology-Biochemistry, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
| |
Collapse
|
38
|
Korang SK, Safi S, Nava C, Greisen G, Gupta M, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013836. [PMID: 33998665 PMCID: PMC8127057 DOI: 10.1002/14651858.cd013836.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units, and observational studies in high-income countries suggest that 83% to 94% of newborns treated with antibiotics for suspected sepsis have negative blood cultures. The last Cochrane Review was updated in 2005. There is a need for an updated systematic review assessing the effects of different antibiotic regimens for late-onset neonatal sepsis. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for late-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2021, Issue 3); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for late-onset neonatal sepsis. We included participants older than 72 hours of life at randomisation, suspected or diagnosed with neonatal sepsis, meningitis, osteomyelitis, endocarditis, or necrotising enterocolitis. We excluded trials that assessed treatment of fungal infections. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (580 participants). All trials were at high risk of bias, and had very low-certainty evidence. The five included trials assessed five different comparisons of antibiotics. We did not conduct a meta-analysis due to lack of relevant data. Of the five included trials one trial compared cefazolin plus amikacin with vancomycin plus amikacin; one trial compared ticarcillin plus clavulanic acid with flucloxacillin plus gentamicin; one trial compared cloxacillin plus amikacin with cefotaxime plus gentamicin; one trial compared meropenem with standard care (ampicillin plus gentamicin or cefotaxime plus gentamicin); and one trial compared vancomycin plus gentamicin with vancomycin plus aztreonam. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. RCTs assessing different antibiotic regimens in late-onset neonatal sepsis with low risks of bias are warranted.
Collapse
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
39
|
Multidrug-Resistant Healthcare-Associated Infections in Neonates with Severe Respiratory Failure and the Impacts of Inappropriate Initial Antibiotic Therap. Antibiotics (Basel) 2021; 10:antibiotics10040459. [PMID: 33919573 PMCID: PMC8072889 DOI: 10.3390/antibiotics10040459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/24/2021] [Accepted: 04/16/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Multidrug-resistant (MDR) pathogens have emerged as an important issue in neonatal intensive care units (NICUs), especially in critically ill neonates with severe respiratory failure. We aimed to investigate neonatal healthcare-associated infections (HAIs) caused by MDR pathogens and the impacts of inappropriate initial antibiotic therapy on the outcomes. Methods: We retrospectively analyzed all cases of HAIs in neonates with severe respiratory failure in a tertiary-level NICU in Taiwan between January 2014 and May 2020. All clinical features, microbiology, therapeutic interventions, and outcomes were compared between the MDR-HAI and non-MDR HAI groups. Multivariate regression analyses were used to investigate independent risk factors for sepsis-attributable mortality. Results: A total of 275 critically ill neonates with severe respiratory failure who had HAIs were enrolled. Ninety-five cases (34.5%) were caused by MDR pathogens, and 141 (51.3%) cases had positive bacterial cultures from multiple sterile sites. In this cohort, the MDR-HAI group was more likely to receive inappropriate initial antibiotic therapy (51.0% versus 4.7%, respectively; p < 0.001) and exhibit delayed control of the infectious focus (52.6% versus 37.8%, respectively; p = 0.021) compared with the non-MDR HAI group. The sepsis-attributable and final in-hospital rates were 21.8% and 37.1%, respectively, and they were comparable between the MDR-HAI and non-MDR HAI groups. Empirically broad-spectrum antibiotics were prescribed in 76.7% of cases, and inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. Independent risk factors for sepsis-attributable mortality in neonates with severe respiratory failure included the presence of septic shock (OR: 3.61; 95% CI: 1.54–8.46; p = 0.003), higher illness severity (OR: 1.33; 95% CI: 1.04–1.72; p = 0.026), and neonates with bronchopulmonary dysplasia (OR: 2.99; 95% CI: 1.47–6.09; p = 0.003). Conclusions: MDR pathogens accounted for 34.5% of all neonatal HAIs in the NICU, but neither MDR pathogens nor inappropriate initial antibiotics were associated with final adverse outcomes. Because the overuse of broad-spectrum antibiotics has emerged as an important issue in critically ill neonates, the implementation of antimicrobial stewardship to promote the appropriate use of antimicrobials is urgently needed.
Collapse
|
40
|
Prusakov P, Goff DA, Wozniak PS, Cassim A, Scipion CE, Urzúa S, Ronchi A, Zeng L, Ladipo-Ajayi O, Aviles-Otero N, Udeigwe-Okeke CR, Melamed R, Silveira RC, Auriti C, Beltrán-Arroyave C, Zamora-Flores E, Sanchez-Codez M, Donkor ES, Kekomäki S, Mainini N, Trochez RV, Casey J, Graus JM, Muller M, Singh S, Loeffen Y, Pérez MET, Ferreyra GI, Lima-Rogel V, Perrone B, Izquierdo G, Cernada M, Stoffella S, Ekenze SO, de Alba-Romero C, Tzialla C, Pham JT, Hosoi K, Consuegra MCC, Betta P, Hoyos OA, Roilides E, Naranjo-Zuñiga G, Oshiro M, Garay V, Mondì V, Mazzeo D, Stahl JA, Cantey JB, Monsalve JGM, Normann E, Landgrave LC, Mazouri A, Avila CA, Piersigilli F, Trujillo M, Kolman S, Delgado V, Guzman V, Abdellatif M, Monterrosa L, Tina LG, Yunis K, Rodriguez MAB, Saux NL, Leonardi V, Porta A, Latorre G, Nakanishi H, Meir M, Manzoni P, Norero X, Hoyos A, Arias D, Sánchez RG, Medoro AK, Sánchez PJ. A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study. EClinicalMedicine 2021; 32:100727. [PMID: 33554094 PMCID: PMC7848759 DOI: 10.1016/j.eclinm.2021.100727] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts. METHODS We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality. FINDINGS On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02). INTERPRETATION Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide. FUNDING Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.
Collapse
Affiliation(s)
- Pavel Prusakov
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Debra A. Goff
- Department of Pharmacy, The Ohio State University Wexner Medical Center, The Ohio State University College of Pharmacy, Columbus, OH, USA
| | | | - Azraa Cassim
- Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | | | - Soledad Urzúa
- Department of Neonatology, Pontificia Universidad Catolica, Santiago, Chile
| | - Andrea Ronchi
- Division of Neonatology and NICU, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lingkong Zeng
- Department of Neonatology, Wuhan Children's Hospital Wuhan Maternal and Child Healthcare Hospital Tongji Medical College Huazhong University of Science & Technology, Wuhan, China
| | | | | | | | - Rimma Melamed
- Pediatric Infectious Diseases Unit and Faculty of Health Sciences, Ben Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
| | - Rita C. Silveira
- Department of Pediatrics, Newborn Section, Universidade Federal do Rio Grande do Sul. Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Cinzia Auriti
- Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Elena Zamora-Flores
- Division of Neonatology, Hospital Materno Infantil Gregorio Marañon University Hospital, Madrid, Spain
| | - Maria Sanchez-Codez
- Division of Pediatric Infectious Diseases, Puerta del Mar University Hospital, Cadiz, Spain
| | - Eric S. Donkor
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Satu Kekomäki
- Division of Pediatric Infectious Diseases, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Jamalyn Casey
- Department of Pharmacy, St. Vincent Women's Hospital, Indianapolis, IN, United States
| | - Juan M. Graus
- Department of Neonatology, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Mallory Muller
- Department of Pharmacy, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Sara Singh
- University of Guyana, School of Medicine, Georgetown, Guyana
| | - Yvette Loeffen
- Division of Pediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - María Eulalia Tamayo Pérez
- Coordinator of Neonatology Fellow Program, Head of Neonatal Intensive Care, University of Antioquia, Hospital San Vicente Fundacion, Medellin, Colombia
| | - Gloria Isabel Ferreyra
- Department of Neonatology, Instituto de Maternidad Ntra. Sra. de las Mercedes, San Miguel de Tucumán, Argentina
| | - Victoria Lima-Rogel
- Division of Neonatology, Hospital General Dr. Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Barbara Perrone
- Division of Neonatology and NICU, G. Salesi Children's Hospital, Ancona, Italy
| | - Giannina Izquierdo
- Division of Neonatology and Pediatric Infectious Diseases, Hospital Barros Luco Trudeau, Santiago, Chile
| | - María Cernada
- Division of Neonatology and Neonatal Research Group, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Sylvia Stoffella
- Department of Pharmacy, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - Jennifer T. Pham
- Department of Pharmacy, University of Illinois Hospital & Health Sciences System, Chicago, IL, USA
| | - Kenichiro Hosoi
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Pasqua Betta
- Division of Neonatology and NICU, AOU Policlinico G Rodolico, Catania, Italy
| | - O. Alvaro Hoyos
- Clínica Universitaria Bolivariana/Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Makoto Oshiro
- Department of Pediatrics, Nagoya Red Cross Daiichi Hospital, Nagoya, Japan
| | - Victor Garay
- Division of Neonatology, Alberto Sabogal Hospital, Lima, Peru
| | | | - Danila Mazzeo
- Division of Patology and Intensive Neonatal Care, A.O.U. Policlinico di Messina, Messina, Italy
| | - James A. Stahl
- Department of Pharmacy, Norton Children's Hospital, Louisville, KY, USA
| | - Joseph B. Cantey
- Department of Pediatrics, Division of Neonatology, University Hospital UT Health San Antonio, San Antonio, TX
| | | | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala University Children's Hospital, Uppsala, Sweden
| | | | - Ali Mazouri
- Iran University of Medical Sciences, Tehran, Iran
| | - Claudia Alarcón Avila
- Department of Perinatology and Neonatology, Central Military Hospital, Nueva Granada Military University, Bogotá, Colombia
| | | | - Monica Trujillo
- Program Coordinator Pediatric Infectious Diseases Clinica Universiraria Bolivariana, Hospital Pablo Tobon Uribe, Medellin, Colombia
| | - Sonya Kolman
- Department of Pharmacy, Nelson Mandela Children Hospital, Johannesburg, South Africa
| | - Verónica Delgado
- Head of Neonatal Intensive Care, Hospital de los Valles, Quito, Ecuador
| | - Veronica Guzman
- Pontificia Universidad Catolica del Ecuador, Hospital Metropolitano Quito, Quito, Ecuador
| | - Mohamed Abdellatif
- Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman
| | - Luis Monterrosa
- Department of Pediatrics, Division of Neonatology, Saint John Regional Hospital, Saint John, Canada
| | | | - Khalid Yunis
- Division of Neonatology, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Nicole Le Saux
- Division of Infectious Disease, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Valentina Leonardi
- Division of Neonatology and NICU, Careggi Univerisity Hospital, Florence, Italy
| | | | | | - Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Department of Advanced Medicine, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Michal Meir
- Division of Pediatric Infectious Diseases, The Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Paolo Manzoni
- Division of Pediatrics and Neonatology, Degli Infermi Hospital, Biella, Italy
| | | | - Angela Hoyos
- Division of Neonatology, Clínica del Country / Clínica La Colina, Bogotá, Colombia
| | | | | | - Alexandra K. Medoro
- The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Pablo J. Sánchez
- The Ohio State University College of Medicine, Columbus, OH, USA
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Corresponding author at: Divisions of Neonatology and Pediatric Infectious Diseases, Nationwide Children's Hospital - The Ohio State University College of Medicine, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, RB3, WB5245, Columbus, Ohio 43205-2664, United States.
| | | |
Collapse
|
41
|
Pyle AK, Cantey JB, Brown LS, Heyne RJ, Wozniak PS, Heyne E, Holcombe A, Brammer EM, Lair CS, Sánchez PJ. Antibiotic exposure and growth patterns in preterm, very low birth weight infants. Matern Health Neonatol Perinatol 2021; 7:7. [PMID: 33514436 PMCID: PMC7846997 DOI: 10.1186/s40748-021-00126-6] [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: 11/09/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic exposure in term infants has been associated with later obesity. Premature, very-low-birth-weight (birth weight ≤ 1500 g) infants in the neonatal intensive care unit frequently are exposed to antibiotics. Our hypothesis was that in preterm infants, there is a positive linear and dose-dependent relationship between antibiotic exposure and growth from birth through 12 months' corrected age. METHODS Retrospective analysis of prospectively collected data of all antibiotic use among inborn, preterm (≤32 weeks' gestation), very-low-birth-weight infants admitted to the neonatal intensive care unit at Parkland Memorial Hospital and followed in the Low Birth Weight Clinic at Children's Medical Center, Dallas, TX. Antibiotic use was quantified by days of therapy which was compared with weight and length parameters at birth, 36 weeks' postmenstrual age, and 2, 4, 6, and 12 months' corrected age. The change in weight and length z-scores from birth to all subsequent age points was calculated. Stepwise multivariate regression analysis was performed to determine predictors of weight, length, and weight-for-length delta z-scores from birth to each subsequent age point. RESULTS During the 18-month study, 161 infants received a median of 11 (IQR, 5.5-19.5) antibiotic days of therapy which was not associated with weight or length delta z-scores from birth through 12 months' corrected age. CONCLUSION Association of prolonged antibiotic use and neonatal morbidities and mortality may override the potential association with increased weight gain in the NICU and beyond.
Collapse
Affiliation(s)
- Alaina K Pyle
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatrics, Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Joseph B Cantey
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - L Steven Brown
- Health System Research, Parkland Health and Hospital System, Dallas, TX, USA
| | - Roy J Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Phillip S Wozniak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | | | | | | | - Cheryl S Lair
- Nutrition Services, Parkland Health and Hospital System, Dallas, TX, USA
| | - Pablo J Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA. .,Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
| |
Collapse
|
42
|
Lonsdale DO, Lipman J. Global personalization of antibiotic therapy in critically ill patients. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1874823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George’s, University of London, London, UK
- Department of Critical Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| |
Collapse
|
43
|
Korang SK, Safi S, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Hippokratia 2021. [DOI: 10.1002/14651858.cd013836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Pediatric Department; Holbaek Sygehus; Holbaek Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Munish Gupta
- Neonatology; Beth Israel Deaconess Medical Center; Boston USA
| | - Gorm Greisen
- Department of Neonatology; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit; Paris South University Hospitals Le Kremlin-Bicêtre; Paris France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
- Department of Regional Health Research, the Faculty of Health Sciences; University of Southern Denmark; Holbaek Denmark
| |
Collapse
|
44
|
Korang SK, Safi S, Gupta M, Gordon A, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Hippokratia 2021. [DOI: 10.1002/14651858.cd013837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Pediatric Department; Holbaek Sygehus; Holbaek Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Munish Gupta
- Neonatology; Beth Israel Deaconess Medical Center; Boston USA
| | | | - Gorm Greisen
- Department of Neonatology; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit; Paris South University Hospitals Le Kremlin-Bicêtre; Paris France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
- Department of Regional Health Research, the Faculty of Health Sciences; University of Southern Denmark; Holbaek Denmark
| |
Collapse
|
45
|
Tusor N, De Cunto A, Basma Y, Klein JL, Meau-Petit V. Ventilator-associated pneumonia in neonates: the role of point of care lung ultrasound. Eur J Pediatr 2021; 180:137-146. [PMID: 32592026 PMCID: PMC7317892 DOI: 10.1007/s00431-020-03710-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/29/2020] [Accepted: 05/29/2020] [Indexed: 12/27/2022]
Abstract
No consensus exists regarding the definition of ventilator-associated pneumonia (VAP) in neonates and reliability of chest X-ray (CXR) is low. Lung ultrasound (LU) is a potential alternative diagnostic tool. The aim was to define characteristics of VAP in our patient population and propose a multiparameter score, incorporating LU, for VAP diagnosis. Between March 25, 2018, and May 25, 2019, infants with VAP were identified. Clinical, laboratory and microbiology data were collected. CXRs and LU scans were reviewed. A multiparameter VAP score, including LU, was calculated on Day 1 and Day 3 for infants with VAP and for a control group and compared with CXR. VAP incidence was 10.47 episodes/1000 ventilator days. LU and CXR were available for 31 episodes in 21 infants with VAP, and for six episodes in five patients without VAP. On Day 1, a VAP score of > 4, and on Day 3 a score of > 5 showed sensitivity of 0.94, and area under the curve of 0.91 and 0.97, respectively. AUC for clinical information only was 0.88 and for clinical and CXR 0.85.Conclusion: The multiparameter VAP score including LU could be useful in diagnosing VAP in neonates with underlying lung pathology. What is Known: • Ventilator associated pneumonia (VAP) is common in infants on the neonatal unit and is associated with increased use of antibiotics, prolonged ventilation and higher incidence of chronic lung disease. • Commonly used definitions of VAP are difficult to apply in neonates and interpretation of chest X-ray is challenging with poor inter-rater agreement in patients with underlying chronic lung disease. What is New: • The multiparameter VAP score combining clinical, microbiology and lung ultrasound (LU) data is predictive for VAP diagnosis in preterm infants with chronic lung disease. • LU findings of VAP in neonates showed high inter-rater agreement and included consolidated lung areas, dynamic bronchograms and pleural effusion.
Collapse
Affiliation(s)
- Nora Tusor
- Neonatal Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
| | - Angela De Cunto
- Neonatal Intensive Care Unit, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 6th floor, Westminster Bridge Road, London, SE1 0EH UK
| | - Yousef Basma
- Neonatal Transfer Service London, Royal London Hospital, Whitechapel Road, London, E1 1FR UK
| | - John L. Klein
- Department of Infectious Diseases, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 2nd floor, Westminster Bridge Road, London, SE1 0EH UK
| | - Virginie Meau-Petit
- Neonatal Intensive Care Unit, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, North Wing 6th floor, Westminster Bridge Road, London, SE1 0EH UK
| |
Collapse
|
46
|
Yochpaz S, Friedman N, Zirkin S, Blumovich A, Mandel D, Marom R. C-reactive protein in early-onset neonatal sepsis - a cutoff point for CRP value as a predictor of early-onset neonatal sepsis in term and late preterm infants early after birth? J Matern Fetal Neonatal Med 2020; 35:4552-4557. [PMID: 33280469 DOI: 10.1080/14767058.2020.1856068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify whether the first plasma C-reactive protein values taken 6-8 h postpartum are predictive of the clinical early-onset neonatal sepsis (cEONS). STUDY DESIGN We retrospectively analyzed C-reactive protein (CRP) values of 400 neonates, including 28 with cEONS, who underwent plasma CRP measurements as part of sepsis work-up. To determine whether the first CRP measurement is predictive of cEONS, logistic regression was used with CRP as an independent variable and cEONS (yes/no) as a dependent variable. RESULT A moderate predictive ability of the first CRP measurement (odds ratio 1.4, CI: [1.13, 1.76], p=.003) was revealed, at a 5.3 mg/L threshold. However, it resulted in poor sensitivity of 50%, and a false positive rate of 30%. Increasing the sensitivity to 75% or 90% lead to increased false-positive rates of 55% and 75%, respectively. CONCLUSIONS Our findings suggest that the first CRP value taken in neonates is a weak predictor of cEONS.
Collapse
Affiliation(s)
- Sivan Yochpaz
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Nati Friedman
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Semyon Zirkin
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Amit Blumovich
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Dror Mandel
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronella Marom
- Department of Neonatology, Faculty of Medicine, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
47
|
Lonsdale DO, Shah RV, Lipman J. Infection, Sepsis and the Inflammatory Response: Mechanisms and Therapy. Front Med (Lausanne) 2020; 7:588863. [PMID: 33344475 PMCID: PMC7738462 DOI: 10.3389/fmed.2020.588863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis secondary to bacterial infection remains a significant cause of morbidity and mortality globally. Recent decades have seen the evolution of international collaborations to improve care for these patients and identify areas for research. In this article we discuss the pathophysiology underlying the condition, review the current recommended management strategies, discuss areas of controversy, and highlight the need for ongoing research, particularly in diagnostics.
Collapse
Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Reya V Shah
- Department of Clinical Pharmacology, St George's University of London, London, United Kingdom.,Department of Critical Care, St George's University Hospitals National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, NÎmes University Hospital, University of Montpellier, NÎmes, France
| |
Collapse
|
48
|
Aleem S, Wohlfarth M, Cotten CM, Greenberg RG. Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit. Semin Perinatol 2020; 44:151326. [PMID: 33158599 PMCID: PMC7550069 DOI: 10.1016/j.semperi.2020.151326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.
Collapse
Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA,Corresponding author at: Department of Pediatrics, Duke University, Durham, NC, USA
| |
Collapse
|
49
|
Abstract
Responsible use of antibiotics is critical to preserve their effectiveness and to minimize adverse outcomes associated with overuse and misuse. Newborn infants are a unique population with high rates of antibiotic exposure. In order to improve neonatal antibiotic use, accurate and meaningful metrics are required. In this review, we highlight and compare existing antibiotic use metrics in detail, including definitions, current applications, advantages, and limitations of each metric, with a focus on applicability to neonatal populations. We explore future directions for identification of accurate and meaningful metrics that will allow hospitals and stakeholders to pinpoint antibiotic utilization practices that should be emulated or avoided, and ultimately improve the safety and quality of neonatal care.
Collapse
|
50
|
Affiliation(s)
- Sagori Mukhopadhyay
- University of Pennsylvania. Division of Neonatology, Children's Hospital of Philadelphia. The Roberts Center for Pediatric Research, 2716 South Street, Office 19-322, Philadelphia, PA 19146, USA
| |
Collapse
|