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Roberts AG, Younge N, Greenberg RG. Neonatal Necrotizing Enterocolitis: An Update on Pathophysiology, Treatment, and Prevention. Paediatr Drugs 2024; 26:259-275. [PMID: 38564081 DOI: 10.1007/s40272-024-00626-w] [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] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
Necrotizing enterocolitis (NEC) is a life-threatening disease predominantly affecting premature and very low birth weight infants resulting in inflammation and necrosis of the small bowel and colon and potentially leading to sepsis, peritonitis, perforation, and death. Numerous research efforts have been made to better understand, treat, and prevent NEC. This review explores a variety of factors involved in the pathogenesis of NEC (prematurity, low birth weight, lack of human breast milk exposure, alterations to the microbiota, maternal and environmental factors, and intestinal ischemia) and reports treatment modalities surrounding NEC, including pain medications and common antibiotic combinations, the rationale for these combinations, and recent antibiotic stewardship approaches surrounding NEC treatment. This review also highlights the effect of early antibiotic exposure, infections, proton pump inhibitors (PPIs), and H2 receptor antagonists on the microbiota and how these risk factors can increase the chances of NEC. Finally, modern prevention strategies including the use of human breast milk and standardized feeding regimens are discussed, as well as promising new preventative and treatment options for NEC including probiotics and stem cell therapy.
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Mara KC, Clark RH, Carey WA. Necrotizing Enterocolitis in Very Low Birth Weight Neonates: A Natural History Study. Am J Perinatol 2024; 41:e435-e445. [PMID: 35554890 DOI: 10.1055/a-1851-1692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE We characterize the most recent natural history of necrotizing enterocolitis (NEC), as this is an essential first step in guiding the prevention and treatment of this disease in the present day. STUDY DESIGN We performed a retrospective cohort study of neonates who were born at 23 to 29 weeks' gestation and birth weight <1,500 g who received care from the Pediatrix Medical Group between 2004 and 2019. We assessed the incidence of medical and surgical NEC and the patterns of initial antibiotic treatment to develop a contemporary cohort for further analysis. Among patients discharged between 2015 and 2019, we characterized the stage-specific risk factors for patients diagnosed with medical or surgical NEC, as well as patterns of disease onset, progression, biomarkers, and outcomes. We used the same approach to characterize patients diagnosed with suspected NEC. RESULTS Among 34,032 patients in the contemporary cohort, 1,150 (3.4%) were diagnosed with medical NEC and 543 (1.6%) were diagnosed with surgical NEC. The temporal pattern of disease onset was different for medical and surgical NEC, with gestational age- and birth weight-specific risk disparities emerging earlier in surgical NEC. Thirty-day mortality was much greater among surgical NEC patients (medical NEC 16.4% vs. surgical NEC 43.0%), as were rates of various in-hospital and long-term outcomes. Suspected NEC was diagnosed in 1,256 (3.7%) patients, among whom risk factors and disease onset, progression, and outcomes closely resembled those of medical NEC. CONCLUSION Analyzing data from a contemporary cohort enabled us to characterize the current, stage-specific natural history of NEC, including novel insights into suspected NEC. Future studies could leverage this cohort to characterize how specific patient characteristics, care processes, or biomarkers may influence or predict disease outcomes. KEY POINTS · The incidence of NEC has reached a stable baseline in recent years.. · Risk factors for NEC vary in a stage-specific manner.. · The stage-specific onset and progression of NEC differ by gestational age and birth weight..
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Affiliation(s)
- Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - William A Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
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Butzer SK, Faust K, Oberthuer A, Kleindiek C, Kuehne B, Haertel C, Mehler K. Wide use of broad-spectrum antibiotics in very low birth weight infants with spontaneous focal intestinal perforation-is it really justified? Infection 2024:10.1007/s15010-024-02257-2. [PMID: 38634989 DOI: 10.1007/s15010-024-02257-2] [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: 12/28/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Very low birth weight (VLBW) infants are at a risk of spontaneous focal intestinal perforation (FIP). Treatment includes supportive care, antibiotics, and drainage with/without surgery. Broad-spectrum antibiotic agents like carbapenems are applied frequently, although their use is not well-supported by the limited evidence of causal pathogens. We hypothesize that the use of carbapenems may not be necessary in VLBW infants with FIP. Our primary objective was to evaluate the antimicrobial use in VLBW infants with FIP in a cohort of the German Neonatal Network (GNN). The secondary objective was to characterize a subset in detail as a benchmark for future targets of stewardship. METHODS Data on VLBW infants with FIP was collected prospectively within the GNN, a collaboration of 68 neonatal intensive care units (NICU). With regards to the primary objective, patient characteristics and antimicrobial treatment were extracted from the predefined GNN database. To address our secondary objective, an additional on-site assessment of laboratory and microbiological culture results were performed. RESULTS In the GNN cohort, 613/21,646 enrolled infants (2.8%) developed FIP requiring surgery. They were frequently treated with carbapenems (500/613 (81.6%)) and vancomycin (497/613 (81.1%)). In a subset of 124 VLBW infants, 77 (72.6%) had proof of gram-positive bacteria in the abdominal cavity, coagulase-negative staphylococci (CoNS) predominantly. Despite the low prevalence of gram-negative bacteria (n = 6 (4.8%)), the combination of meropenem and vancomycin was prescribed most frequently (n = 96 (78.0%)). CONCLUSION The use of carbapenems as broad-spectrum antimicrobials agents might not be justified in most VLBW infants with FIP. Knowledge on the development of the neonatal gut microbiota, local resistance patterns and individual microbiological findings should be taken into consideration when implementing antimicrobial stewardship programs (ASPs).
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Affiliation(s)
- Sarina K Butzer
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Kirstin Faust
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - André Oberthuer
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | | | - Benjamin Kuehne
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christoph Haertel
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
- German Neonatal Network (GNN), Lübeck, Germany
| | - Katrin Mehler
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany.
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Randell RL, Balevic SJ, Greenberg RG, Cohen-Wolkowiez M, Thompson EJ, Venkatachalam S, Smith MJ, Bendel C, Bliss JM, Chaaban H, Chhabra R, Dammann CEL, Downey LC, Hornik C, Hussain N, Laughon MM, Lavery A, Moya F, Saxonhouse M, Sokol GM, Trembath A, Weitkamp JH, Hornik CP. Opportunistic dried blood spot sampling validates and optimizes a pediatric population pharmacokinetic model of metronidazole. Antimicrob Agents Chemother 2024; 68:e0153323. [PMID: 38477706 PMCID: PMC10994817 DOI: 10.1128/aac.01533-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
Pharmacokinetic models rarely undergo external validation in vulnerable populations such as critically ill infants, thereby limiting the accuracy, efficacy, and safety of model-informed dosing in real-world settings. Here, we describe an opportunistic approach using dried blood spots (DBS) to evaluate a population pharmacokinetic model of metronidazole in critically ill preterm infants of gestational age (GA) ≤31 weeks from the Metronidazole Pharmacokinetics in Premature Infants (PTN_METRO, NCT01222585) study. First, we used linear correlation to compare 42 paired DBS and plasma metronidazole concentrations from 21 preterm infants [mean (SD): post natal age 28.0 (21.7) days, GA 26.3 (2.4) weeks]. Using the resulting predictive equation, we estimated plasma metronidazole concentrations (ePlasma) from 399 DBS collected from 122 preterm and term infants [mean (SD): post natal age 16.7 (15.8) days, GA 31.4 (5.1) weeks] from the Antibiotic Safety in Infants with Complicated Intra-Abdominal Infections (SCAMP, NCT01994993) trial. When evaluating the PTN_METRO model using ePlasma from the SCAMP trial, we found that the model generally predicted ePlasma well in preterm infants with GA ≤31 weeks. When including ePlasma from term and preterm infants with GA >31 weeks, the model was optimized using a sigmoidal Emax maturation function of postmenstrual age on clearance and estimated the exponent of weight on volume of distribution. The optimized model supports existing dosing guidelines and adds new data to support a 6-hour dosing interval for infants with postmenstrual age >40 weeks. Using an opportunistic DBS to externally validate and optimize a metronidazole population pharmacokinetic model was feasible and useful in this vulnerable population.
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Affiliation(s)
- Rachel L. Randell
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stephen J. Balevic
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Elizabeth J. Thompson
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Michael J. Smith
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Catherine Bendel
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Joseph M. Bliss
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Hala Chaaban
- Division of Neonatology, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rakesh Chhabra
- Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | | | - L. Corbin Downey
- Department of Pediatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Chi Hornik
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Naveed Hussain
- Division of Neonatology, Department of Pediatrics, Connecticut Children’s, Hartford, Connecticut, USA
| | - Matthew M. Laughon
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Specialties, Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew Saxonhouse
- Division of Neonatology, Department of Pediatrics, Levine Children’s Hospital, Wake Forest School of Medicine, Charlotte campus, Atrium Healthcare, Charlotte, North Carolina, USA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea Trembath
- Division of Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joern-Hendrik Weitkamp
- Mildred Stahlman Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Best Pharmaceuticals for Children Act – Pediatric Trials Network Steering Committee
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
- Division of Neonatology, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
- Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey, USA
- Department of Pediatrics, Tufts Medical Center, Tufts University, Boston, Massachusetts, USA
- Department of Pediatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
- Division of Neonatology, Department of Pediatrics, Connecticut Children’s, Hartford, Connecticut, USA
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Loma Linda University, Loma Linda, California, USA
- Division of Wilmington Pediatric Specialties, Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
- Division of Neonatology, Department of Pediatrics, Levine Children’s Hospital, Wake Forest School of Medicine, Charlotte campus, Atrium Healthcare, Charlotte, North Carolina, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Mildred Stahlman Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Aurora M, Keyes ML, Acosta JG, Swartz K, Lombay J, Ciaramitaro J, Rudnick A, Kelleher C, Hally S, Gee M, Madhavan V, Roumiantsev S, Cummings BM, Nelson BD, Lerou PH, Matute JD. Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU. Pediatrics 2022; 150:189570. [PMID: 36164852 PMCID: PMC10026590 DOI: 10.1542/peds.2022-056616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.
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Affiliation(s)
- Megan Aurora
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors contributed equally to this work
| | - Madeline L Keyes
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- Harvard Neonatal-Perinatal Medicine Fellowship Program, Boston, Massachusetts
- These authors contributed equally to this work
| | | | | | - Jesiel Lombay
- Divisions of aNewborn Medicine
- Departments of Pediatrics
| | | | | | | | | | - Michael Gee
- Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Paul H Lerou
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
| | - Juan D Matute
- Divisions of aNewborn Medicine
- Departments of Pediatrics
- These authors co-supervised this work
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