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Flannery DD, Coggins SA, Medoro AK. Antibiotic Stewardship in the Neonatal Intensive Care Unit. J Intensive Care Med 2024:8850666241258386. [PMID: 38835250 DOI: 10.1177/08850666241258386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
Antibiotic stewardship is a multidisciplinary, evidence-based approach to optimize antibiotic use and mitigate development of antibiotic resistance. Neonates have high rates of antibiotic exposure, particularly those born preterm and admitted to the NICU, and mounting evidence describes the adverse consequences of such exposures in the absence of infection. Here, we review the general principles of antibiotic stewardship and how they can be applied in NICUs. The unique characteristics of NICUs and patients cared for in this setting, which warrant unique implementation strategies and special considerations are discussed. We summarize current antibiotic use metrics for assessment of responses to stewardship interventions and changes over time, and review evidence-based infection prevention practices in the NICU. Current recommendations for empiric antibiotic use in the NICU and the utility of infection biomarkers are summarized. Lastly, given the growing global threat of increasing antibiotic resistance, specific threats in the NICU are highlighted.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarah A Coggins
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra K Medoro
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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2
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Truong-Bolduc QC, Wang Y, Ferrer-Espada R, Reedy JL, Martens AT, Goulev Y, Paulsson J, Vyas JM, Hooper DC. Staphylococcus aureus AbcA transporter enhances persister formation under β-lactam exposure. Antimicrob Agents Chemother 2024; 68:e0134023. [PMID: 38364015 PMCID: PMC10916373 DOI: 10.1128/aac.01340-23] [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: 10/12/2023] [Accepted: 01/18/2024] [Indexed: 02/18/2024] Open
Abstract
We evaluated the role of Staphylococcus aureus AbcA transporter in bacterial persistence and survival following exposure to the bactericidal agents nafcillin and oxacillin at both the population and single-cell levels. We show that AbcA overexpression resulted in resistance to nafcillin but not oxacillin. Using distinct fluorescent reporters of cell viability and AbcA expression, we found that over 6-14 hours of persistence formation, the proportion of AbcA reporter-expressing cells assessed by confocal microscopy increased sixfold as cell viability reporters decreased. Similarly, single-cell analysis in a high-throughput microfluidic system found a strong correspondence between antibiotic exposure and AbcA reporter expression. Persister cells grown in the absence of antibiotics showed neither an increase in nafcillin MIC nor in abcA transcript levels, indicating that survival was not associated with stable mutational resistance or abcA overexpression. Furthermore, persister cell levels on exposure to 1×MIC and 25×MIC of nafcillin decreased in an abcA knockout mutant. Survivors of nafcillin and oxacillin treatment overexpressed transporter AbcA, contributing to an enrichment of the number of persisters during treatment with pump-substrate nafcillin but not with pump-non-substrate oxacillin, indicating that efflux pump expression can contribute selectively to the survival of a persister population.
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Affiliation(s)
- Q. C. Truong-Bolduc
- Infectious Diseases Division and Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Y. Wang
- Infectious Diseases Division and Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - R. Ferrer-Espada
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - J. L. Reedy
- Infectious Diseases Division and Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - A. T. Martens
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Y. Goulev
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Paulsson
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - J. M. Vyas
- Infectious Diseases Division and Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - D. C. Hooper
- Infectious Diseases Division and Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dumont O, Iacono D, Jacob A, Aggarwal A, Hagmann SHF. Experience With a Vancomycin-sparing Empiric Antibiotic Guideline for Late-onset Sepsis in a Level-4 Neonatal Intensive Care Unit. Pediatr Infect Dis J 2024; 43:e49-e51. [PMID: 38108378 DOI: 10.1097/inf.0000000000004172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
A vancomycin-sparing guideline for suspected late-onset sepsis helped reduce vancomycin usage in our level-4 neonatal intensive care unit. Significant reduction in overall vancomycin use, with its likely unit-wide beneficial downstream effects, may need to be measured against the rare case of methicillin-resistant Staphylococcus aureus infection and delayed effective therapy.
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Affiliation(s)
- Olivia Dumont
- From the Department of Pharmacy
- Steven and Alexandra Cohen Children's Medical Center of New York/Northwell Health, New Hyde Park, New York
| | - Denise Iacono
- From the Department of Pharmacy
- Steven and Alexandra Cohen Children's Medical Center of New York/Northwell Health, New Hyde Park, New York
| | - Alby Jacob
- From the Department of Pharmacy
- Steven and Alexandra Cohen Children's Medical Center of New York/Northwell Health, New Hyde Park, New York
| | - Alpna Aggarwal
- Steven and Alexandra Cohen Children's Medical Center of New York/Northwell Health, New Hyde Park, New York
- Division of Neonatal Medicine
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York
| | - Stefan H F Hagmann
- Steven and Alexandra Cohen Children's Medical Center of New York/Northwell Health, New Hyde Park, New York
- Division of Pediatric Infectious Diseases
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York
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Cernada M, De Alba Romero C, Fernández-Colomer B, González-Pacheco N, González M, Couce ML. Health care-associated infections in neonatology. An Pediatr (Barc) 2024; 100:46-56. [PMID: 38177038 DOI: 10.1016/j.anpede.2023.12.004] [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: 10/10/2023] [Accepted: 11/27/2023] [Indexed: 01/06/2024] Open
Abstract
Health care-associated infections are common in neonatology, but there is no consensus on their definitions. This makes it difficult to compare their incidence or assess the effectiveness of prevention bundles. This is why we think it is very important to achieve a consensus on the definitions and diagnostic criteria for one of the most frequent causes of morbidity in hospitalised neonates. This document aims to standardise the definitions for the most frequent health care-associated infections, such as catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical wound infection, as well as the approach to their diagnosis and treatment.
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Affiliation(s)
- María Cernada
- Servicio de Neonatología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - María González
- Servicio de Neonatología, Hospital Materno-Infantil Regional Málaga, Málaga, Spain
| | - María Luz Couce
- Servicio de Neonatología, Hospital Clínico Universitario de Santiago, IDIS, Universidad de Santiago, Santiago de Compostela, Spain.
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Speier RL, Cotten CM, Benjamin DK, Lewis K, Keeler K, Kidimbu G, Roberts W, Clark RH, Zimmerman KO, Stark A, Greenberg RG. Late-Onset Sepsis Evaluation and Empiric Therapy in Extremely Low Gestational Age Newborns. J Pediatric Infect Dis Soc 2023; 12:S37-S43. [PMID: 38146858 DOI: 10.1093/jpids/piad068] [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: 06/20/2023] [Accepted: 09/12/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Little is known about late-onset sepsis (LOS) evaluations in extremely low gestational age newborns (ELGANs). We describe frequencies of LOS evaluation in ELGANs, infant characteristics, and empiric therapy choices during evaluations. METHODS Cohort study of infants 22-28 weeks gestational age (GA) discharged from 243 centers from 2009 to 2018, excluding infants with congenital anomalies, discharged or deceased prior to postnatal day (PND) 2, or admitted after PND 2. A new LOS evaluation was defined as the first blood culture obtained between PND 3 and 90, or one obtained ≥1 day following a negative culture and ≥10 days from prior positive cultures. We determined numbers of evaluations and percentage positive by GA, center, and over time. We described characteristics associated with positive evaluations, infants with LOS, and empiric antimicrobials. We calculated descriptive and comparative statistics using Wilcoxon rank sum, Fisher's exact, or Pearson chi-square tests, as appropriate. RESULTS Of 47,187 included infants, 67% had ≥1 LOS evaluation and 21% of evaluated infants had ≥1 LOS (culture positive) episode; 1.6 evaluations occurred per infant and 10% were positive. The percentage of infants evaluated and positive for LOS was higher at earlier GA. LOS was associated with inotrope support (15% vs. 9%; p < .001) and invasive mechanical ventilation (66% vs. 51%; p < .001). Infants with positive cultures were more likely than infants with negative cultures to receive empiric antimicrobials during the LOS evaluation (95% vs. 73%; p < .001). CONCLUSIONS Among ELGANs, earlier GA and postnatal age were associated with LOS evaluation and positive cultures. Most infants undergoing evaluation were started on empiric antimicrobials.
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Affiliation(s)
| | | | - Daniel K Benjamin
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
| | - Kelsey Lewis
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Reese H Clark
- Pediatrix Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | - Kanecia O Zimmerman
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
| | - Ashley Stark
- Department of Medicine, Duke University School of Medicine
| | - Rachel G Greenberg
- Department of Medicine, Duke University School of Medicine
- Duke Clinical Research Institute, Durham, NC, USA
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Lewald ZS, Prusakov P, Magers JK, Kielt MJ, de Alba Romero C, White NO, Miller RR, Moraille R, Theile AR, Sánchez PJ. Short-course antibiotic therapy for pneumonia in the neonatal intensive care unit. J Perinatol 2023; 43:1145-1151. [PMID: 37438484 DOI: 10.1038/s41372-023-01720-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To determine the adherence and safety outcomes of a 5-day antibiotic course with a "time-out" for treatment of "blood culture-negative" pneumonia in the NICU. STUDY DESIGN Prospective surveillance of all infants diagnosed with pneumonia at 7 NICUs from 8/2020-12/2021. Safety outcomes were defined a priori by re-initiation of antibiotic therapy within 14 days after discontinuation and overall and sepsis-related mortality. RESULTS 128 infants were diagnosed with 136 episodes of pneumonia; 88% (n = 119) were treated with 5 days of definitive antibiotic therapy. Antibiotics were restarted within 14 days in 22 (16%) of the 136 pneumonia episodes. However, only 3 (3%) of the 119 episodes of pneumonia treated for 5 days had antibiotics restarted for pneumonia. Mortality was 5% (7/128); 5 of the 7 deaths were assessed as sepsis-related. CONCLUSION Adherence to the 5-day definitive antibiotic treatment for "culture-negative" pneumonia was high and the intervention seemed safe.
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Affiliation(s)
- Zachery S Lewald
- The Ohio State University, Columbus, OH, USA
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Pavel Prusakov
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Matthew J Kielt
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Concepción de Alba Romero
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Neonatology, Hospital 12 de Octubre, Madrid, Spain
| | | | | | | | | | - Pablo J Sánchez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Neonatology, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA.
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Sánchez PJ, Prusakov P, de Alba Romero C, Zamora-Flores E, Reyes Escamilla MC, White NO, Miller RR, Moraille R, Theile AR, Magers JK. Short-course empiric antibiotic therapy for possible early-onset sepsis in the NICU. J Perinatol 2023; 43:741-745. [PMID: 36813903 DOI: 10.1038/s41372-023-01634-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/05/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE On 2/2019, the Neonatal Antimicrobial Stewardship Program at Nationwide Children's Hospital recommended reducing empirical antibiotic therapy for early-onset sepsis (EOS) from 48 to 24 hours with a TIME-OUT. We describe our experience with this guideline and assess its safety. METHODS Retrospective review of newborns evaluated for possible EOS at 6 NICUs from 12/2018-7/2019. Safety endpoints were re-initiation of antibiotics within 7 days after discontinuation of the initial course, positive bacterial blood or cerebrospinal fluid culture in the 7 days after antibiotic discontinuation, and overall and sepsis-related mortality. RESULT Among 414 newborns evaluated for EOS, 196 (47%) received a 24 hour rule-out sepsis antibiotic course while 218 (53%) were managed with a 48 hour course. The 24-hour rule-out group were less likely to have antibiotics re-initiated and did not differ in the other predefined safety endpoints. CONCLUSION Antibiotic therapy for suspected EOS may be discontinued safely within 24 hours.
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Affiliation(s)
- Pablo J Sánchez
- Divisions of Neonatology and Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Pavel Prusakov
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Concepción de Alba Romero
- Division of Neonatology, Department of Pediatrics, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Division of Neonatology, Hospital 12 de Octubre, Madrid, Spain
| | - Elena Zamora-Flores
- Division of Neonatology, Department of Pediatrics, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Division of Neonatology, Gregorio Marañon University Hospital, Madrid, Spain
| | - María Camila Reyes Escamilla
- Division of Neonatology, Department of Pediatrics, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Division of Neonatology, Universidad del Valle, Cali, Colombia
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Flannery DD, Edwards EM, Coggins SA, Horbar JD, Puopolo KM. Late-Onset Sepsis Among Very Preterm Infants. Pediatrics 2022; 150:e2022058813. [PMID: 36366916 PMCID: PMC11151779 DOI: 10.1542/peds.2022-058813] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine the epidemiology, microbiology, and associated outcomes of late-onset sepsis among very preterm infants using a large and nationally representative cohort of NICUs across the United States. METHODS Prospective observational study of very preterm infants born 401 to 1500 g and/or 22 to 29 weeks' gestational age (GA) from January 1, 2018, to December 31, 2020, who survived >3 days in 774 participating Vermont Oxford Network centers. Late-onset sepsis was defined as isolation of a pathogenic bacteria from blood and/or cerebrospinal fluid, or fungi from blood, obtained >3 days after birth. Demographics, clinical characteristics, and outcomes were compared between infants with and without late-onset sepsis. RESULTS Of 118 650 infants, 10 501 (8.9%) had late-onset sepsis for an incidence rate of 88.5 per 1000 (99% confidence interval [CI] [86.4-90.7]). Incidence was highest for infants born ≤23 weeks GA (322.0 per 1000, 99% CI [306.3-338.1]). The most common pathogens were coagulase negative staphylococci (29.3%) and Staphylococcus aureus (23.0%), but 34 different pathogens were identified. Infected infants had lower survival (adjusted risk ratio [aRR] 0.89, 95% CI [0.87-0.90]) and increased risks of home oxygen (aRR 1.32, 95% CI [1.26-1.38]), tracheostomy (aRR 2.88, 95% CI [2.47-3.37]), and gastrostomy (aRR 2.09, 95% CI [1.93-2.57]) among survivors. CONCLUSIONS A substantial proportion of very preterm infants continue to suffer late-onset sepsis, particularly those born at the lowest GAs. Infected infants had higher mortality, and survivors had increased risks of technology-dependent chronic morbidities. The persistent burden and diverse microbiology of late-onset sepsis among very preterm infants underscore the need for innovative and potentially organism-specific prevention strategies.
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Affiliation(s)
- Dustin D. Flannery
- Division of Neonatology
- Clinical Futures, Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Larner College of Medicine
- College of Engineering and Mathematical Sciences at the University of Vermont, Burlington, Vermont
- Vermont Oxford Network, Burlington, Vermont
| | - Sarah A. Coggins
- Division of Neonatology
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jeffrey D. Horbar
- Larner College of Medicine
- Vermont Oxford Network, Burlington, Vermont
| | - Karen M. Puopolo
- Division of Neonatology
- Clinical Futures, Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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