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Huncikova Z, Stensvold HJ, Øymar KAA, Vatne A, Lang AM, Støen R, Brigtsen AK, Moster D, Eriksen BH, Selberg T, Rønnestad A, Klingenberg C. Variation in antibiotic consumption in very preterm infants-a 10 year population-based study. J Antimicrob Chemother 2024; 79:143-150. [PMID: 37986613 PMCID: PMC10761275 DOI: 10.1093/jac/dkad358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES Wide variations in antibiotic use in very preterm infants have been reported across centres despite similar rates of infection. We describe 10 year trends in use of antibiotics and regional variations among very preterm infants in Norway. PATIENTS AND METHODS All live-born very preterm infants (<32 weeks gestation) admitted to any neonatal unit in Norway during 2009-18 were included. Main outcomes were antibiotic consumption expressed as days of antibiotic therapy (DOT) per 1000 patient days (PD), regional variations in use across four health regions, rates of sepsis and sepsis-attributable mortality and trends of antibiotic use during the study period. RESULTS We included 5296 infants: 3646 (69%) were born at 28-31 weeks and 1650 (31%) were born before 28 weeks gestation with similar background characteristics across the four health regions. Overall, 80% of the very preterm infants received antibiotic therapy. The most commonly prescribed antibiotics were the combination of narrow-spectrum β-lactams and aminoglycosides, but between 2009 and 2018 we observed a marked reduction in their use from 100 to 40 DOT per 1000 PD (P < 0.001). In contrast, consumption of broad-spectrum β-lactams remained unchanged (P = 0.308). There were large variations in consumption of vancomycin, broad-spectrum β-lactams and first-generation cephalosporins, but no differences in sepsis-attributable mortality across regions. CONCLUSIONS The overall antibiotic consumption was reduced during the study period. Marked regional variations remained in consumption of broad-spectrum β-lactams and vancomycin, without association to sepsis-attributable mortality. Our results highlight the need for antibiotic stewardship strategies to reduce consumption of antibiotics that may enhance antibiotic resistance development.
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Affiliation(s)
- Zuzana Huncikova
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Asbjørn Alexander Øymar
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anlaug Vatne
- Paediatric Department, Stavanger University Hospital, Stavanger, Norway
| | - Astri Maria Lang
- Paediatric Department, Akershus University Hospital, Lørenskog, Norway
| | - Ragnhild Støen
- Department of Paediatrics, St.Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Karin Brigtsen
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Dag Moster
- Department of Paediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Terje Selberg
- Department of Paediatric and Adolescent Medicine, Ostfold County Hospital, Gralum, Norway
| | - Arild Rønnestad
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Paediatric and Adolescent Medicine, Ostfold County Hospital, Gralum, Norway
- Medical Faculty, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claus Klingenberg
- Department of Paediatrics and Adolescent Medicine, University Hospital of North Norway, Tromsø, Norway
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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2
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Mahieu L, Engelen A, Hensels E, Van Damme K, Matheeussen V. Surveillance on meticillin-sensitive Staphylococcus aureus colonization and infection in a neonatal intensive care unit. J Hosp Infect 2024; 143:195-202. [PMID: 37858807 DOI: 10.1016/j.jhin.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Meticillin-sensitive Staphylococcus aureus (MSSA) infection is a significant health concern in neonatal intensive care units (NICUs). Bacterial colonization increases the risk of subsequent infection, leading to morbidity and mortality. AIM To report the findings of a retrospective cohort study on the surveillance of MSSA colonization and infection in NICU patients. METHODS The weekly microbial surveillance results for MSSA colonization in the throat, nose, anus, and groin, as well as invasive and non-invasive MSSA infections, were analysed from November 2020 to June 2022. The MSSA infection and colonization risk were compared after adjustment for confounders by stepwise logistic regression analysis. FINDINGS Three hundred and eighty-three neonates were screened; 42.8% (N=164) were MSSA colonized. Significant risk factors for MSSA colonization were length of stay, vaginal delivery and extreme low gestational age <28 weeks (ELGAN) (all P<0.05). The surveillance detected 38 (9.9%) mild MSSA infections and 11 (2.9%) invasive MSSA infections. Neonatal colonization with MSSA is a major risk factor for MSSA infection overall (29.3% in colonized/infected vs 70.7% colonized/not-infected and 0.5% in not-colonized/infected vs 99.5% in not-colonized/not-infected infants) and invasive MSSA infections (6.1% in colonized/infected vs 93.9% in colonized/not-infected and 0.5% in non-colonized/infected vs 99.5% not-colonized/not-infected infants). Also, extreme low birth weight (<1000 g), ELGAN and invasive ventilation were significant risk factors for MSSA infections (all, P<0.05). CONCLUSIONS The link between postnatal MSSA colonization and subsequent MSSA infection offers possibilities for prevention. Additional research is needed to explore the association between vaginal birth and the pathogenesis of neonatal MSSA colonization.
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Affiliation(s)
- L Mahieu
- Department of Neonatal Intensive Care, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - A Engelen
- Department of Neonatal Intensive Care, Antwerp University Hospital, Edegem, Belgium
| | - E Hensels
- Department of Neonatal Intensive Care, Antwerp University Hospital, Edegem, Belgium
| | - K Van Damme
- Department of Neonatal Intensive Care, Antwerp University Hospital, Edegem, Belgium
| | - V Matheeussen
- Department of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
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3
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Richter LL, Ho MSP, Dunn MS, Lee KS, Robinson JL, Roberts A, Thampi N, Gupta-Bhatnagar S, Shah PS, Ting JY. Antibiotic use in Canadian neonatal intensive care units: a national survey for developing antimicrobial stewardship targets. Infect Control Hosp Epidemiol 2023; 44:2092-2095. [PMID: 37314127 DOI: 10.1017/ice.2023.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A survey was conducted among Canadian tertiary neonatal intensive care units. Of the 27 sites who responded, 9 did not have any form of antimicrobial stewardship, and 11 used vancomycin for empirical coverage in late-onset-sepsis evaluations. We detected significant variations in the diagnostic criteria for urinary tract infection and ventilator-associated pneumonia.
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Affiliation(s)
- Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Michael S Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Kyong-Soon Lee
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Joan L Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nisha Thampi
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Prakesh S Shah
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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4
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Cook A, Atkinson A, Kronenberg A, Agyeman PKA, Schlapbach LJ, Berger C, Bielicki JA. Estimating antibiotic coverage from linked microbiological and clinical data from the Swiss Paediatric Sepsis Study to support empiric antibiotic regimen selection. Front Pediatr 2023; 11:1124165. [PMID: 37252038 PMCID: PMC10213904 DOI: 10.3389/fped.2023.1124165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/20/2023] [Indexed: 05/31/2023] Open
Abstract
In light of rising antibiotic resistance, better methods for selection of empiric antibiotic treatment based on clinical and microbiological data are needed. Most guidelines target specific clinical infections, and variably adjust empiric antibiotic selection by certain patient characteristics. Coverage estimates reflect the probability that an antibiotic regimen will be active against the causative pathogen once confirmed and can provide an objective basis for empiric regimen selection. Coverage can be estimated for specific infections using a weighted incidence syndromic combination antibiograms (WISCAs) framework. However, no comprehensive data combining clinical and microbiological data for specific clinical syndromes are available in Switzerland. We therefore describe estimating coverage from semi-deterministically linked routine microbiological and cohort data of hospitalised children with sepsis. Coverage estimates were generated for each hospital and separately pooling data across ten contributing hospitals for five pre-defined patient risk groups. Data from 1,082 patients collected during the Swiss Paediatric Sepsis Study (SPSS) 2011-2015 were included. Preterm neonates were the most commonly represented group, and half of infants and children had a comorbidity. 67% of neonatal sepsis cases were hospital-acquired late-onset whereas in children 76% of infections were community-acquired. Escherichia coli, Coagulase-negative staphylococci (CoNS) and Staphylococcus aureus were the most common pathogens. At all hospitals, ceftazidime plus amikacin regimen had the lowest coverage, and coverage of amoxicillin plus gentamicin and meropenem were generally comparable. Coverage was improved when vancomycin was included in the regimen, reflecting uncertainty about the empirically targeted pathogen spectrum. Children with community-acquired infections had high coverage overall. It is feasible to estimate coverage of common empiric antibiotic regimens from linked data. Pooling data by patient risk groups with similar expected pathogen and susceptibility profiles may improve coverage estimate precision, supporting better differentiation of coverage between regimens. Identification of data sources, selection of regimens and consideration of pathogens to target for improved empiric coverage is important.
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Affiliation(s)
- Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London, United Kingdom
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Andrew Atkinson
- Pediatric Research Centre, University Children's Hospital Basel, Basel, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Philipp K. A. Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University children's Hospital Zürich, Zürich, Switzerland
| | | | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Julia Anna Bielicki
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London, United Kingdom
- Pediatric Research Centre, University Children's Hospital Basel, Basel, Switzerland
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5
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Lee TY, Hung YL, Shen CM, Kao CL, Hsieh WS. Reappraisal of therapeutic vancomycin trough concentrations with empirical dosing in neonatal infections. Pediatr Neonatol 2022; 64:176-182. [PMID: 36344414 DOI: 10.1016/j.pedneo.2022.05.018] [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: 12/25/2021] [Revised: 04/06/2022] [Accepted: 05/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Vancomycin is commonly used for neonatal sepsis. However, consensus on an empirical neonatal vancomycin regimen remains uncertain. We aimed to reappraise the therapeutic optimum concerning vancomycin trough concentrations with empirical dosing and to evaluate the relationship between trough concentrations and predicted 24-h area under the curve (AUC24). METHODS This was a 3-year retrospective study. Neonates who were admitted to the neonatal intensive care unit with available vancomycin trough concentrations were enrolled. Trough levels were obtained before the fourth dose. Achievement of goal trough after implementing the vancomycin dosing regimen was based on the Practical Neonatology Medical Manual, published by the National Taiwan University College of Medicine. RESULTS A total of 46 neonates were included for analysis. Coagulase-negative staphylococci were the most commonly identified pathogens of sepsis. Among these patients, 22 achieved goal trough levels of 10-20 mcg/mL. Trough levels of 5-10 or >20 mcg/mL occurred in 13 and 11 patients, respectively. A moderately positive correlation between trough and predicted AUC24 was found in all patients (Spearman's rho = 0.676, p < 0.001). In patients with body weight 1200-2000 g and postnatal age >7 days, the serum creatinine of those with trough levels >20 mcg/mL was significantly higher than those with goal trough levels (0.61 vs. 0.45 mg/dL, p = 0.01). Among those with trough levels >20 mcg/mL, 5 patients received ibuprofen for patent ductus arteriosus closing prior to vancomycin treatment (45%, 5/11), compared to only 3 patients with trough levels <20 mcg/mL (9%, 3/35) (p = 0.013). CONCLUSION Only half of the neonates receiving empirical vancomycin regimen achieved goal trough levels of 10-20 mcg/mL. Higher serum creatinine or ibuprofen treatment may increase the risk of overly high trough levels. The vancomycin regimen needs further validation and modification to provide adequate dosing for optimal use in neonates.
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Affiliation(s)
- Tzung-Yi Lee
- Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan
| | - Yi-Li Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chung-Min Shen
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Lan Kao
- Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan.
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6
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Magers J, Prusakov P, Speaks S, Conroy S, Sánchez PJ. Safety and Efficacy of Nafcillin for Empiric Therapy of Late-Onset Sepsis in the NICU. Pediatrics 2022; 149:186703. [PMID: 35380005 DOI: 10.1542/peds.2021-052360] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE In 2014 at Nationwide Children's Hospital, the Neonatal Antimicrobial Stewardship Program recommended nafcillin over vancomycin for empirical therapy of possible late-onset sepsis (LOS) in infants without a history of methicillin-resistant Staphylococcus aureus colonization or infection. We report our experience with this guideline and assess its safety. METHODS We retrospectively reviewed all infants who received nafcillin or vancomycin for empirical treatment of possible LOS at 3 NICUs before (January 2013-May 2014) and after (January 2017-March 2019) implementation of a vancomycin reduction guideline. Safety measures included duration of blood culture positivity, recurrence of infection with the same previously identified pathogen in the 14 days after discontinuation of antibiotic therapy, and mortality. RESULTS Among 366 infants who received a first antibiotic course for possible LOS, 84% (95 of 113) and 25% (62 of 253) received empirical therapy with vancomycin before and after the guideline implementation, respectively, representing a 70% reduction. Nafcillin use increased by 368%. Duration of blood culture positivity did not differ before and after the guidance. In 2 infants, antibiotic therapy was restarted within 14 days of discontinuation of the initial therapy for recurrence of the same infection; both had received empirical vancomycin. Overall in-hospital mortality was 10%, and there was no difference before (9%) and after (10%) implementation of the vancomycin reduction guidance (odds ratio, 0.97). CONCLUSIONS Nafcillin can be a safe alternative to vancomycin for empirical therapy of LOS among NICU infants who do not have a history of methicillin-resistant S aureus infection or colonization.
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Affiliation(s)
| | | | - Sunday Speaks
- Department of Pharmacy, Riverside Methodist Hospital, Columbus, Ohio
| | - Sara Conroy
- Biostatistics Resource at Nationwide Children's Hospital(BRANCH), Nationwide Children's Hospital, Columbus, Ohio.,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Pablo J Sánchez
- Divisions of Neonatology and Pediatric Infectious Diseases, Departments of Pediatrics.,Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
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7
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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8
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Antimicrobial use for treatment of healthcare-associated infections and bacterial resistance in a reference neonatal unit. J Pediatr (Rio J) 2021; 97:329-334. [PMID: 32592659 PMCID: PMC9432030 DOI: 10.1016/j.jped.2020.06.001] [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: 01/28/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The use of broad-spectrum antimicrobials, such as third and fourth-generation, are responsible for emergence of multidrug-resistant microorganisms in neonatal units. Furthermore, antimicrobial daily doses are not standardized in neonatology. This study aimed to investigate the association between the use of antimicrobial broad spectrum to bacterial sensitivity profile in a referral unit of neonatal progressive care. METHODS This is a cohort study conducted in a referral neonatal progressive care unit from January 2008 to December 2016. The data of all hospitalized neonates was collected daily. The infection criteria used were the standardized national criteria, based on definitions of Center for Diseases Control and Prevention. In this study, the use of antimicrobials was evaluated as antimicrobial-day (ATM-day) and the ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was also calculated. The study was approved by the Institutional Review Board of the Universidade Federal de Minas Gerais (ETIC 312/08 e CAAE 58973616.2.0000.5149). RESULTS From 2008 to 2016, 2751 neonates were hospitalized, corresponding to 60,656 patient-days. The ratio of multidrug-resistant microorganisms per 1000 ATM-day of broad spectrum was 1,3 in the first period and 4,3 in the second period (p=0,005). CONCLUSION It was observed that use of broad-spectrum antimicrobials, especially those with coverage for Gram-negative bacteria, was associated with an increase of multidrug-resistant bacteria.
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9
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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.
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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
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10
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Every Minute Counts: The Urgency of Identifying Infants with Sepsis. J Pediatr 2020; 217:10-12. [PMID: 31668480 DOI: 10.1016/j.jpeds.2019.09.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 12/15/2022]
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11
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Impact of Peptide Nucleic Acid Fluorescence in Situ Hybridization Testing for Coagulase-Negative Staphylococci in a Pediatric Setting. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Wagstaff JS, Durrant RJ, Newman MG, Eason R, Ward RM, Sherwin CMT, Enioutina EY. Antibiotic Treatment of Suspected and Confirmed Neonatal Sepsis Within 28 Days of Birth: A Retrospective Analysis. Front Pharmacol 2019; 10:1191. [PMID: 31680968 PMCID: PMC6803465 DOI: 10.3389/fphar.2019.01191] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023] Open
Abstract
Neonatal sepsis causes significant mortality and morbidity worldwide. Diagnosis is usually confirmed via blood culture results. Blood culture sepsis confirmation can take days and suffer from contamination and false negatives. Empiric therapy with antibiotics is common. This study aims to retrospectively describe and compare treatments of blood culture-confirmed and unconfirmed, but suspected, sepsis within the University of Utah Hospital system. Electronic health records were obtained from 1,248 neonates from January 1, 2006, to December 31, 2017. Sepsis was categorized into early-onset (≤3 days of birth, EOS) and late-onset (>3 and ≤28 days of birth, LOS) and categorized as culture-confirmed sepsis if a pathogen was cultured from the blood and unconfirmed if all blood cultures were negative with no potentially contaminated blood cultures. Of 1,010 neonates in the EOS cohort, 23 (2.3%) were culture-confirmed, most with Escherichia coli (42%). Treatment for unconfirmed EOS lasted an average of 6.1 days with primarily gentamicin and ampicillin while confirmed patients were treated for an average of 12.3 days with increased administration of cefotaxime. Of 311 neonates in the LOS cohort, 62 (20%) were culture-confirmed, most culturing coagulase negative staphylococci (46%). Treatment courses for unconfirmed LOS lasted an average of 7.8 days while confirmed patients were treated for an average of 11.4 days, these patients were primarily treated with vancomycin and gentamicin. The use of cefotaxime for unconfirmed EOS and LOS increased throughout the study period. Cefotaxime administration was associated with an increase in neonatal mortality, even when potential confounding factors were added to the logistic regression model (adjusted odds ratio 2.8, 95%CI [1.21, 6.88], p = 0.02). These results may not be generalized to all hospitals and the use of cefotaxime may be a surrogate for other factors. Given the low rate of blood culture positive diagnosis and the high exposure rate of empiric antibiotics, this patient population might benefit from improved diagnostics with reevaluation of antibiotic use guidelines.
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Affiliation(s)
- Jadon S Wagstaff
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Robert J Durrant
- Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Michael G Newman
- University of Utah Health Science Center, Salt Lake City, UT, United States
| | - Rachael Eason
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States.,Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University, Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, United States
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States.,Division of Medical Laboratory Science, Department of Pathology, School of Medicine, University of Utah, Salt Lake City, UT, United States.,Pharmaceutics & Pharmaceutical Chemistry, College of Pharmacy, University of Utah, Salt Lake City, UT, United States
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13
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Kyo M, Ohshimo S, Kosaka T, Fujita N, Shime N. Impact of inappropriate empiric antimicrobial therapy on mortality in pediatric patients with bloodstream infection: a retrospective observational study. J Chemother 2019; 31:388-393. [PMID: 31145044 DOI: 10.1080/1120009x.2019.1623362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Inappropriate empiric antibiotic therapy for bloodstream infection could be associated with mortality in adults. However, data for pediatric patients have been scarce. The purpose of this study was to investigate the impact of an inappropriate empiric antibiotic therapy on mortality in pediatric patients with bloodstream infection. We retrospectively analyzed the data of pediatric patients with consecutive positive blood culture in the university hospital between 2007 and 2016. The association between the use of inappropriate empiric therapy and mortality was investigated. A total of 247 bacteremia events in 223 pediatric patients were analyzed. Overall, 208 (84%) events were hospital acquired and 16 (6%) patients died within 28 days. The most frequent causative microorganisms were Gram-positive bacteria (150 events, 61%), followed by Gram-negative bacteria (90 events, 36%) and Candida spp. (7 events, 3%). Inappropriate empiric antibiotic therapy was prescribed within 48 h in 34 (16%) events. Significantly better 28-day survival rates were obtained in patients that received appropriate empiric antibiotic therapy compared with those who received inappropriate therapy (p = 0.004). Multivariate Cox regression analysis showed that inappropriate empiric antibiotic therapy was an independent prognostic factor of 28-day mortality (hazard ratio, 4.39; 95% confidence interval, 1.48-11.94; p = 0.01), after adjusting for age and McCabe score. Inappropriate empiric antibiotic therapy was associated with poor 28-day mortality in pediatric patients with bloodstream infection. Strategies to increase appropriate selection of empiric antibiotic therapy might be an option for improving survival in pediatric patients with bloodstream infection.
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Affiliation(s)
- Michihito Kyo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tadashi Kosaka
- Department of Infection Control and Clinical Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Fujita
- Department of Infection Control and Clinical Laboratory, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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14
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Mukhopadhyay S, Sengupta S, Puopolo KM. Challenges and opportunities for antibiotic stewardship among preterm infants. Arch Dis Child Fetal Neonatal Ed 2019; 104:F327-F332. [PMID: 30425110 PMCID: PMC6491257 DOI: 10.1136/archdischild-2018-315412] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/13/2018] [Accepted: 10/18/2018] [Indexed: 12/20/2022]
Abstract
Antibiotic stewardship programmes aim to optimise antimicrobial use to prevent the emergence of resistance species and protect patients from the side effects of unnecessary medication. The high incidence of systemic infection and associated mortality from these infections leads neonatal providers to frequently initiate antibiotic therapy and make empiric antibiotic courses one of the main contributors of antibiotic use in the neonatal units. Yet, premature infants are also at risk for acute life-threatening complications associated with antibiotic use such as necrotising enterocolitis and for long-term morbidities such as asthma. In this review, we discuss specific aspects of antibiotic use in the very low birthweight preterm infants, with a focus on empiric use, that provide opportunities for stewardship practice. We discuss strategies to risk-stratify antibiotic initiation for the risk of early-onset sepsis, optimise empiric therapy duration and antibiotic choice in late-onset sepsis, and standardise decisions for stopping empiric therapy. Lastly, review the evolving role of biomarkers in antibiotic stewardship.
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Affiliation(s)
- Sagori Mukhopadhyay
- Division of Neonatology, Children’s Hospital of Philadelphia,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shaon Sengupta
- Division of Neonatology, Children’s Hospital of Philadelphia,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Karen M. Puopolo
- Division of Neonatology, Children’s Hospital of Philadelphia,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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15
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Gkentzi D, Kortsalioudaki C, Cailes BC, Zaoutis T, Kopsidas J, Tsolia M, Spyridis N, Siahanidou S, Sarafidis K, Heath PT, Dimitriou G. Epidemiology of infections and antimicrobial use in Greek Neonatal Units. Arch Dis Child Fetal Neonatal Ed 2019; 104:F293-F297. [PMID: 29954881 DOI: 10.1136/archdischild-2018-315024] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/07/2018] [Accepted: 06/09/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe the epidemiology of neonatal infections and of antimicrobial use in Greek Neonatal Units (NNUs) in order to develop national, evidence-based guidelines on empiric antimicrobial use for neonatal sepsis in Greece. DESIGN Retrospective analysis of prospectively collected infection surveillance data from 2012 to 2015, together with a Point Prevalence Survey (PPS) on antimicrobial use and the collection of data on local empiric antimicrobial policies. SETTING 16 NNUs in Greece participating in the neonIN infection surveillance network PATIENTS: Newborns in participating NNUs who had a positive blood, cerebrospinal fluid or urine culture and were treated with at least 5 days of antibiotics. RESULTS 459 episodes were recorded in 418 infants. The overall incidence of infection was 50/1000 NNU-admissions. The majority of episodes were late-onset sepsis (LOS) (413, 90%). Coagulase-negative Staphylococci (80%) were the most common Gram-positive organisms causing LOS and Klebsiella spp (39%) the most common Gram-negative. Nearly half (45%) of the Klebsiella spp were resistant to at least one aminoglycoside. The PPS revealed that 196 of 484 (40%) neonates were on antimicrobials. The survey revealed wide variation in empiric antimicrobial policies for LOS. CONCLUSIONS This is the largest collection of data on the epidemiology of neonatal infections in Greece and on neonatal antimicrobial use. It provides the background for the development of national evidence-based guidelines. Continuous surveillance, the introduction of antimicrobial stewardship interventions and evidence-based guidelines are urgently required.
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Affiliation(s)
- Despoina Gkentzi
- Department of Paediatrics, Patras Medical School, University Hospital of Patras, Patras, Greece
| | | | | | - Theoklis Zaoutis
- The Stavros Niarchos Foundation-Collaborative Centre for Clinical Epidemiology and Outcomes Research, School of Medicine, University of Athens, Athens, Greece
| | - John Kopsidas
- The Stavros Niarchos Foundation-Collaborative Centre for Clinical Epidemiology and Outcomes Research, School of Medicine, University of Athens, Athens, Greece
| | - Maria Tsolia
- Paediatric Infectious Diseases Unit, Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Nikos Spyridis
- Paediatric Infectious Diseases Unit, Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Soultana Siahanidou
- Neonatal Unit, First Department of Pediatrics, Athens University Medical School, Athens, Greece
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care Unit, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Gabriel Dimitriou
- Department of Paediatrics, Patras Medical School, University Hospital of Patras, Patras, Greece
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16
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Litz JE, Goedicke-Fritz S, Härtel C, Zemlin M, Simon A. Management of early- and late-onset sepsis: results from a survey in 80 German NICUs. Infection 2019; 47:557-564. [DOI: 10.1007/s15010-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
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17
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Han W, Cao Y. [Research advances in rational use of antibiotics in neonates]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:876-880. [PMID: 30369368 PMCID: PMC7389037 DOI: 10.7499/j.issn.1008-8830.2018.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/04/2018] [Indexed: 06/08/2023]
Abstract
Antibiotics are commonly used in the neonatal intensive care unit (NICU), but unnecessary or long-time exposure to antibiotics early after birth can increase the risk of poor prognosis of neonates. Antibiotic treatment in the NICU often begins with empiric therapy, but no uniform standards have been established for the initiation and course of empiric therapy. In neonates with negative bacterial culture results and stable clinical manifestations, empiric antibiotic therapy should be terminated in a timely manner. There are significant differences in the use of antibiotics in different NICUs. A targeted antimicrobial stewardship program is an effective way for optimizing the use of antibiotics in the NICU.
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Affiliation(s)
- Wen Han
- Department of Pediatrics, Karamay Central Hospital, Karamay, Xinjiang 834000, China.
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18
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McPherson C, Liviskie C, Zeller B, Nelson MP, Newland JG. Antimicrobial Stewardship in Neonates: Challenges and Opportunities. Neonatal Netw 2018; 37:116-123. [PMID: 29615159 DOI: 10.1891/0730-0832.37.2.116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonatal infections result in significant morbidity and mortality. Antibiotics are vital for the treatment of infections but disrupt the neonatal microbiome, put the infant at risk for an adverse drug reaction, and may lead to the development of antibiotic resistance. Immediately after birth, clinicians must determine which infants require empiric antibiotics. Online risk stratification tools may provide a superior approach to decision trees. In infants who require empiric therapy for early-onset sepsis, ampicillin and an aminoglycoside with dosing based on recent pharmacokinetic studies represents the most appropriate first-line agents; third-generation cephalosporins should be reserved for patients with a high likelihood of Gram-negative meningitis. An antistaphylococcal penicillin and gentamicin should be utilized for suspected late-onset sepsis. Vancomycin and other broad-spectrum agents are reserved for patients with a history of resistant organisms. Antibiotic duration should be guided by understanding the clinical indications and obtaining the necessary cultures appropriately (i.e., adequate volume blood cultures). In the absence of a positive culture, antibiotic duration should often be limited. Individual institutions should leverage a multidisciplinary, interprofessional team to identify opportunities for antimicrobial stewardship. A collaborative, transparent system is required to change unit culture and generate a sustained impact on antibiotic utilization with optimal patient outcomes.
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19
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Cantey JB, Anderson KR, Kalagiri RR, Mallett LH. Morbidity and mortality of coagulase-negative staphylococcal sepsis in very-low-birth-weight infants. World J Pediatr 2018. [PMID: 29536341 DOI: 10.1007/s12519-018-0145-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Coagulase-negative staphylococci (CoNS) are the most common cause of late-onset sepsis in the neonatal intensive care unit (NICU) and usually require vancomycin treatment. Our objective was to determine whether CoNS are associated with neonatal morbidity and mortality. METHODS This was a retrospective cohort study of very-low-birth-weight (VLBW, ≤ 1500 g) infants from 1989 to 2015. Exclusion criteria were major congenital anomaly or death within 72 h. CoNS was considered a pathogen if recovered from ≥ 2 cultures, or 1 culture if treated for ≥ 5 days and signs of sepsis were present. Logistic regression was used to examine factors associated with morbidity and mortality. RESULTS Of 2242 VLBW infants, 285 (12.7%) had late-onset sepsis. CoNS (125, 44%), Staphylococcus aureus (52, 18%), and Escherichia coli (36, 13%) were the most commonly recovered organisms. In multivariate analysis, CoNS sepsis was not associated with mortality [OR 0.6 (95% CI 0.2-2.6)), but sepsis with other organisms was [OR 4.5 (95% CI 2.6-8.0)]. CoNS sepsis was associated with longer hospitalization but not risk for bronchopulmonary dysplasia, intraventricular hemorrhage, or retinopathy of prematurity. CONCLUSION CoNS sepsis was not associated with mortality or morbidities other than length of stay. These findings support vancomycin-reduction strategies in the NICU.
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Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, University of Texas Health Science Center San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
| | | | - Ram R Kalagiri
- Texas A&M Health Science Center, Baylor/Scott & White Health, Temple, TX, USA
| | - Lea H Mallett
- Texas A&M Health Science Center, Baylor/Scott & White Health, Temple, TX, USA
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20
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Sass L, Karlowicz MG. Healthcare-Associated Infections in the Neonate. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2018. [PMCID: PMC7152335 DOI: 10.1016/b978-0-323-40181-4.00094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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21
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Doernberg SB, Lodise TP, Thaden JT, Munita JM, Cosgrove SE, Arias CA, Boucher HW, Corey GR, Lowy FD, Murray B, Miller LG, Holland TL. Gram-Positive Bacterial Infections: Research Priorities, Accomplishments, and Future Directions of the Antibacterial Resistance Leadership Group. Clin Infect Dis 2017; 64:S24-S29. [PMID: 28350900 DOI: 10.1093/cid/ciw828] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antimicrobial resistance in gram-positive bacteria remains a challenge in infectious diseases. The mission of the Gram-Positive Committee of the Antibacterial Resistance Leadership Group (ARLG) is to advance knowledge in the prevention, management, and treatment of these challenging infections to improve patient outcomes. Our committee has prioritized projects involving methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) due to the scope of the medical threat posed by these pathogens. Approved ARLG projects involving gram-positive pathogens include (1) a pharmacokinetics/pharmacodynamics study to evaluate the impact of vancomycin dosing on patient outcome in MRSA bloodstream infection (BSI); (2) defining, testing, and validating innovative assessments of patient outcomes for clinical trials of MRSA-BSI; (3) testing new strategies for "step-down" antibiotic therapy for MRSA-BSI; (4) management of staphylococcal BSIs in neonatal intensive care units; and (5) defining the impact of VRE bacteremia and daptomycin susceptibility on patient outcomes. This article outlines accomplishments, priorities, and challenges for research of infections caused by gram-positive organisms.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, University of California, San Francisco
| | | | - Joshua T Thaden
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Jose M Munita
- Division of Infectious Diseases, University of Texas Health Sciences Center, Houston.,Clinica Alemana, Universidad del Desarrollo, Chile
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cesar A Arias
- Center for Antimicrobial Resistance and Microbial Genomics, Division of Infectious Diseases, University of Texas Health Sciences Center, Houston
| | - Helen W Boucher
- Division of Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - G Ralph Corey
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Franklin D Lowy
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York
| | - Barbara Murray
- Division of Infectious Diseases, University of Texas Health Sciences Center, Houston
| | - Loren G Miller
- Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California; and
| | - Thomas L Holland
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina.,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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22
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Carr JP, Burgner DP, Hardikar RS, Buttery JP. Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units. J Paediatr Child Health 2017; 53:680-684. [PMID: 28421643 DOI: 10.1111/jpc.13540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/24/2016] [Accepted: 01/08/2017] [Indexed: 11/29/2022]
Abstract
AIM Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens. METHODS The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014. RESULTS All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice. CONCLUSIONS There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.
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Affiliation(s)
- Jeremy P Carr
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - David P Burgner
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Rohan S Hardikar
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Jim P Buttery
- Department of Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
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23
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Ramasethu J. Prevention and treatment of neonatal nosocomial infections. Matern Health Neonatol Perinatol 2017; 3:5. [PMID: 28228969 PMCID: PMC5307735 DOI: 10.1186/s40748-017-0043-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/27/2017] [Indexed: 12/02/2022] Open
Abstract
Nosocomial or hospital acquired infections threaten the survival and neurodevelopmental outcomes of infants admitted to the neonatal intensive care unit, and increase cost of care. Premature infants are particularly vulnerable since they often undergo invasive procedures and are dependent on central catheters to deliver nutrition and on ventilators for respiratory support. Prevention of nosocomial infection is a critical patient safety imperative, and invariably requires a multidisciplinary approach. There are no short cuts. Hand hygiene before and after patient contact is the most important measure, and yet, compliance with this simple measure can be unsatisfactory. Alcohol based hand sanitizer is effective against many microorganisms and is efficient, compared to plain or antiseptic containing soaps. The use of maternal breast milk is another inexpensive and simple measure to reduce infection rates. Efforts to replicate the anti-infectious properties of maternal breast milk by the use of probiotics, prebiotics, and synbiotics have met with variable success, and there are ongoing trials of lactoferrin, an iron binding whey protein present in large quantities in colostrum. Attempts to boost the immunoglobulin levels of preterm infants with exogenous immunoglobulins have not been shown to reduce nosocomial infections significantly. Over the last decade, improvements in the incidence of catheter-related infections have been achieved, with meticulous attention to every detail from insertion to maintenance, with some centers reporting zero rates for such infections. Other nosocomial infections like ventilator acquired pneumonia and staphylococcus aureus infection remain problematic, and outbreaks with multidrug resistant organisms continue to have disastrous consequences. Management of infections is based on the profile of microorganisms in the neonatal unit and community and targeted therapy is required to control the disease without leading to the development of more resistant strains.
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Affiliation(s)
- Jayashree Ramasethu
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, MedStar Georgetown University Hospital, Washington DC, 20007 USA
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24
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Furuichi M, Miyairi I. Risk factors for persistent bacteremia in infants with catheter-related bloodstream infection due to coagulase-negative Staphylococcus in the neonatal intensive care unit. J Infect Chemother 2016; 22:785-789. [PMID: 27645121 DOI: 10.1016/j.jiac.2016.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/12/2016] [Accepted: 08/16/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Coagulase-negative Staphylococcus (CoNS) is the predominant cause of catheter-related bloodstream infections (CRBSI). Infants in neonatal intensive care units (NICU) often suffer from CoNS CRBSI, which are often refractory to treatment. OBJECTIVES We sought to evaluate risk factors for developing persistent bacteremia due to CoNS CRBSI in infants, in order to identify those who require early aggressive management. METHODS We conducted a retrospective case-control study of infants in the NICU who developed CRBSI due to CoNS. Patient demographics, condition and management of CRBSI were compared between those with persistent and non-persistent bacteremia. Furthermore, prognosis of infants in the NICU after CoNS CRBSI was evaluated. RESULTS Seventy six episodes of CRBSI, including 17 persistent bacteremia and 59 non-persistent bacteremia, were analyzed. In univariate analyses, persistent bacteremia was significantly associated with corrected age equivalent to gestational age of 22-28 weeks at onset of CRBSI [Odds ratio (OR) = 4.33; P = 0.04], platelet count <100,000/μL (OR = 11.5; P < 0.001), use of vasopressor (OR = 5.38; P = 0.003), and delayed CVC removal (OR = 6.25; P = 0.003). In multivariate analysis, persistent bacteremia was significantly associated with platelet count <100,000/μL (OR = 7.80; P = 0.007), and delayed CVC removal (OR = 5.07; P = 0.03). Infants with persistent bacteremia tended to have a lower survival rate after CoNS CRBSI, however this was not statistically significant (P = 0.21). CONCLUSIONS Early CVC removal should be considered for the treatment of CRBSI due to CoNS in infants with platelet counts of less than 100,000/μL.
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Affiliation(s)
- Munehiro Furuichi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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25
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Sánchez PJ, Moallem M, Cantey JB, Milton A, Michelow IC. Empiric therapy with vancomycin in the neonatal intensive care unit: let's "get smart" globally! J Pediatr (Rio J) 2016; 92:432-5. [PMID: 27343632 DOI: 10.1016/j.jped.2016.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Pablo J Sánchez
- Center for Perinatal Research, Division of Neonatology, Columbus, United States; The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, United States.
| | - Mohannad Moallem
- Center for Perinatal Research, Division of Neonatology, Columbus, United States; The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, United States
| | - Joseph B Cantey
- Texas A&M Health Science Center College of Medicine, Baylor Scott & White, Temple, United States
| | - Avante Milton
- The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, United States
| | - Ian C Michelow
- Rhode Island Hospital, Providence, United States; Alpert Medical School of Brown University, Providence, United States
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26
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Empirical antimicrobial therapy for late-onset sepsis in a neonatal unit with high prevalence of coagulase-negative Staphylococcus. J Pediatr (Rio J) 2016; 92:472-8. [PMID: 27112033 DOI: 10.1016/j.jped.2016.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/18/2016] [Accepted: 01/18/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare two different empiric treatments for late-onset neonatal sepsis, vancomycin and oxacillin, in a neonatal intensive care unit with a high prevalence of coagulase-negative Staphylococcus. METHODS A cross-sectional study was conducted in an neonatal intensive care unit from 2011 to 2014. Data from the medical records of at-risk newborns were collected daily. Infections were defined according to the National Health Surveillance Agency criteria. Data analysis was performed using an internal program. RESULTS There was a significant reduction in the number of Staphylococcus aureus infections (p=0.008), without endocarditis, meningitis, or lower respiratory tract infection, as well as a reduction in the frequency of deaths related to S. aureus infection. There were no significant changes in the incidence of Gram-negative bacterial or fungal infections. An increase in coagulase-negative Staphylococcus infections was observed (p=0.022). However, there was no measured increase in related morbidity and mortality. There was a reduction in the median number of days of treatment with oxacillin from 11.5 to 6 days (p<0.001) and an increase of one day in the median number of days of treatment with vancomycin (p=0.046). CONCLUSIONS Modification of the empiric treatment regimen for neonatal late-onset sepsis with use of oxacillin showed a significant reduction in S. aureus infections, as well as a reduction in the frequency of infections with major organ system involvement and mortality due to infection with this microorganism. As a result, oxacillin can be considered as an effective treatment for late-onset sepsis, making it possible to avoid broad-spectrum antibiotics.
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27
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Sánchez PJ, Moallem M, Cantey JB, Milton A, Michelow IC. Empiric therapy with vancomycin in the neonatal intensive care unit: let's “get smart” globally! JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Empirical antimicrobial therapy for late‐onset sepsis in a neonatal unit with high prevalence of coagulase‐negative Staphylococcus. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Hammer BM, Lardieri AB, Morgan JA. Appropriate Use of Vancomycin in NICU Despite Free-for-All Policy. J Pediatr Pharmacol Ther 2016; 21:207-12. [PMID: 27453698 DOI: 10.5863/1551-6776-21.3.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Because of increases in antimicrobial resistance, the use of vancomycin in late-onset sepsis has come under scrutiny. The primary outcome of this study was to determine if vancomycin for the treatment of late-onset sepsis in the neonatal intensive care unit (NICU) was being discontinued within 72 hours according to the existing protocol. Secondary outcomes included the appropriateness of therapeutic drug monitoring associated with vancomycin, and renal dysfunction associated with the use of vancomycin in the NICU outside of the 72-hour policy. METHODS A retrospective chart review was completed for patients in the NICU who received vancomycin for the treatment of late-onset sepsis between the dates of January 1, 2014, and July 1, 2014. RESULTS There were 125 vancomycin treatment courses, of which 97 were included. Appropriate use of vancomycin, per policy, occurred in a total of 87 of 97 courses (89.6%). Therapeutic drug monitoring was evaluated by the number of appropriate troughs, determined using renal function and previous trough concentrations. There was not a statistically significant difference in the number of inappropriate troughs drawn between those that were continued on vancomycin appropriately (n = 17 courses; 4 of 44 inappropriate troughs) versus inappropriately (n = 10 courses; 1 of 22 inappropriate troughs; p = 0.66), despite the large number of troughs drawn. Adverse renal outcomes were not statistically significant in patients continued inappropriately on vancomycin (p = 1.0). CONCLUSIONS Vancomycin use in the NICU for late-onset sepsis is appropriate per the existing antibiotic policy. Therapeutic drug monitoring could be improved, and adverse renal outcomes due to inappropriate continuation of vancomycin are rare.
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Affiliation(s)
| | - Allison B Lardieri
- Department of Pharmacy Practice and Science, The University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Jill A Morgan
- Department of Pharmacy Practice and Science, The University of Maryland School of Pharmacy, Baltimore, Maryland
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Coggins SA, Weitkamp JH, Grunwald L, Stark AR, Reese J, Walsh W, Wynn JL. Heart rate characteristic index monitoring for bloodstream infection in an NICU: a 3-year experience. Arch Dis Child Fetal Neonatal Ed 2016; 101:F329-32. [PMID: 26518312 PMCID: PMC4851911 DOI: 10.1136/archdischild-2015-309210] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/11/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) among neonatal intensive care unit (NICU) infants is a frequent problem associated with poor outcomes. Monitoring for abnormal heart rate characteristics (HRCs) may decrease infant mortality by alerting clinicians to sepsis before it becomes clinically apparent. METHODS HRC scores were acquired using the HRC (HeRO) monitor system from Medical Predictive Science Corporation and entered into the electronic medical record by bedside staff. We retrospectively analysed HRC scores recorded twice daily in the medical record during a 30-month period (1 January 2010 through 30 June 2012) for infants in the NICU at the Monroe Carell Jr. Children's Hospital at Vanderbilt. We identified infants that met Centers for Disease Control criteria for late-onset BSI (>3 days of life) during the study period. RESULTS During the study period, we recorded 127 673 HRC scores from 2384 infants. We identified 46 infants with BSI. Although 8% (9701/127 673) of the HRC scores were ≥2 and 1% (1387/127 673) were ≥5, BSI (at any time) was observed in just 5% of patients with HRC scores ≥2, and 9% of patients with HRC scores ≥5. Of infants with BSI, 5/46 (11%) had at least one HRC score ≥5 and 17/46 (37%) had at least one score ≥2 recorded in the 48 h period prior to the evaluation that resulted in the first positive blood culture of the episode. CONCLUSIONS In our single-centre retrospective study, elevated HRC scores had limited ability to detect BSI. BSI was infrequent at any time during hospitalisation in infants with significantly elevated HRC scores.
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Affiliation(s)
- Sarah A. Coggins
- Department of Pediatrics, Children’s Hospital of Philadelphia, Pennsylvania
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics, Division of Neonatology, Vanderbilt University, Nashville, Tennessee
| | - Lisa Grunwald
- Department of Pediatrics, Division of Neonatology, Vanderbilt University, Nashville, Tennessee
| | - Ann R. Stark
- Department of Pediatrics, Division of Neonatology, Vanderbilt University, Nashville, Tennessee
| | - Jeff Reese
- Department of Pediatrics, Division of Neonatology, Vanderbilt University, Nashville, Tennessee
| | - William Walsh
- Department of Pediatrics, Division of Neonatology, Vanderbilt University, Nashville, Tennessee
| | - James L. Wynn
- Department of Pediatrics, Division of Neonatology, University of Florida, Gainesville, Florida
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Abstract
PURPOSE OF REVIEW Antibiotics have not only saved lives and improved outcomes, but they also influence the evolving microbiome. This review summarizes reports on neonatal infections and variation in antibiotic utilization, discusses the emergence of resistant organisms, and presents data from human neonates and animal models demonstrating the impact of antibiotics on the microbiome, and how microbiome alterations impact health. The importance of antibiotic stewardship is also discussed. RECENT FINDINGS Infections increase neonatal morbidity and mortality. Furthermore, the clinical presentation of infections can be subtle, prompting clinicians to empirically start antibiotics when infection is a possibility. Antibiotic-resistant infections are a growing problem. Cohort studies have identified extensive center variations in antibiotic usage and associations between antibiotic exposures and outcomes. Studies of antibiotic-induced microbiome alterations and downstream effects on the developing immune system have increased our understanding of the mechanisms underlying the associations between antibiotics and adverse outcomes. The emergence of resistant microorganisms and recent evidence linking antibiotic practice variations with health outcomes has led to the initiation of antibiotic stewardship programs. SUMMARY The review encourages practitioners to assess local antibiotic use with regard to local microbiology, and to adopt steps to reduce infections and use antibiotics wisely.
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