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Strunk T, Molloy EJ, Mishra A, Bhutta ZA. Neonatal bacterial sepsis. Lancet 2024; 404:277-293. [PMID: 38944044 DOI: 10.1016/s0140-6736(24)00495-1] [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: 11/02/2022] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 07/01/2024]
Abstract
Neonatal sepsis remains one of the key challenges of neonatal medicine, and together with preterm birth, causes almost 50% of all deaths globally for children younger than 5 years. Compared with advances achieved for other serious neonatal and early childhood conditions globally, progress in reducing neonatal sepsis has been much slower, especially in low-resource settings that have the highest burden of neonatal sepsis morbidity and mortality. By contrast to sepsis in older patients, there is no universally accepted neonatal sepsis definition. This poses substantial challenges in clinical practice, research, and health-care management, and has direct practical implications, such as diagnostic inconsistency, heterogeneous data collection and surveillance, and inappropriate treatment, health-resource allocation, and education. As the clinical manifestation of neonatal sepsis is frequently non-specific and the current diagnostic standard blood culture has performance limitations, new improved diagnostic techniques are required to guide appropriate and warranted antimicrobial treatment. Although antimicrobial therapy and supportive care continue as principal components of neonatal sepsis therapy, refining basic neonatal care to prevent sepsis through education and quality improvement initiatives remains paramount.
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Affiliation(s)
- Tobias Strunk
- Neonatal Directorate, King Edward Memorial Hospital, Child and Adolescent Health Service, Perth, WA, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, University of Dublin and Trinity Research in Childhood Centre, Dublin, Ireland; Children's Health Hospital at Tallaght, Tallaght University Hospital, Dublin, Ireland; Trinity Translational Medicine Institute, St James Hospital, Dublin, Ireland; Neonatology, Children's Health Hospital at Crumlin, Dublin, Ireland; Paediatrics, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Archita Mishra
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute for Global Health and Development, The Aga Khan University South-Central Asia, Karachi, Pakistan
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Langer BI, Johansson AB, Mathé K, Jourdain S, Smeesters PR. Use of the "Sepsis Risk Calculator" in Belgian Newborns: A Retrospective Cohort Study. Pediatr Infect Dis J 2024; 43:559-564. [PMID: 38380927 DOI: 10.1097/inf.0000000000004290] [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: 02/22/2024]
Abstract
BACKGROUND Prevention of early-onset neonatal sepsis (EONS) is a frequent reason why many newborns receive unnecessary antibiotics. The Sepsis Risk Calculator (SRC) was developed by the Kaiser Permanente Institute as a multivariate risk assessment of EONS, aiming to reduce laboratory testing and empiric neonatal antibiotic therapy. Our objective was to assess the potential of the SRC in reducing antibiotic use in our setting. METHODS Late preterm and term newborns who received antibiotics from 2019 to 2020 in a tertiary Belgian hospital were included. Newborn-specific data were collected and entered into the online SRC, retrospectively calculating a sepsis risk score and providing recommendations for antibiotic administration. False-positive indications for treatment by the SRC were estimated based on previously published data. Antibiotic therapy rates according to the SRC recommendations were compared to the actual rate of antibiotic therapy. RESULTS Of 5891 births, 414 newborns received antibiotics and were eligible for this study, representing a rate of 7.6% of newborns receiving antibiotics following our current guidelines. The SRC would have recommended antibiotic administration for 2.7%, reducing antibiotic therapy by 64.5%. Of 5 possible cases of EONS, 3 would have received antibiotics in the first 24 hours according to the SRC. CONCLUSIONS In this Belgian cohort, use of the SRC has the potential to significantly decrease by 64.5% the newborns that receive antibiotics. This reduction would primarily concern asymptomatic newborns. If use of the SRC was to be implemented in Belgian maternities, strict clinical surveillance practices should be ensured.
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Affiliation(s)
- Bianca I Langer
- From the Department of Pediatrics, Infectious Disease Unit, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles
| | - Anne-Britt Johansson
- Department of Pediatrics, Neonatal Intensive Care Unit, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles
| | - Karin Mathé
- Department of Pediatrics, Neonatal Intensive Care Unit, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles
- Maternity and Non-intensive Neonatal Care Unit, Centre Hospitalier Universitaire Brugmann
| | - Sarah Jourdain
- From the Department of Pediatrics, Infectious Disease Unit, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre R Smeesters
- From the Department of Pediatrics, Infectious Disease Unit, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université Libre de Bruxelles, Brussels, Belgium
- Tropical Diseases Research Group, Murdoch Children's Research Institute
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Tramontano AL, Menichini D, Lazzarin S, Sponzilli A, Zinani I, Facchinetti F, Berardi A. Exposure to Prolonged Rupture of Membranes at Term Increases the Risk for Ventilatory Support in Uninfected Neonates. Am J Perinatol 2024; 41:e2279-e2285. [PMID: 37311542 DOI: 10.1055/a-2109-4109] [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: 06/15/2023]
Abstract
OBJECTIVE The effects of prolonged rupture of membranes (ROMs) on perinatal outcomes are still unclear, and it remains controversial for the management of those labors. This study aims to evaluate how the exposure of pregnant women to a prolonged ROM (≥ 24 hours) affects maternal and neonatal outcomes. STUDY DESIGN This retrospective cohort study included singleton pregnant women at term delivering between January 2019 and March 2020 in a tertiary hospital. All relevant sociodemographic, pregnancy, and perinatal variables (maternal age, prepregnancy body mass index, labor, and delivery outcomes) were collected anonymously. Data were compared between the "ROM < 24 hours" and "ROM ≥ 24 hours" study groups. RESULTS A total of 2,689 dyads were included in the study and divided according to their ROM-delivery time: ROM <24 hours (2,369 women, 88.1%), and ROM ≥ 24 hours (320 women, 11.9%). Maternal baseline characteristics were comparable except for the rate of nulliparous women, which was significantly higher among patients with ROM ≥ 24 hours. No significant differences were found regarding infectious neonatal outcomes. However, mechanical ventilation and continuous positive airway pressure were more common among neonates born after ROM ≥ 24 hours. The greater likelihood of neonatal respiratory distress was also confirmed among infants born to Group-B Streptococcus-negative women with ROM ≥ 24 hours (15 out of 267 neonates, 5.6% vs. 52 out of 1,529 with ROM < 24 hours, 3.4%, p = 0.04). CONCLUSION According to the actual expectant policy, prolonged ROM is associated with an increased risk of respiratory support in noninfected neonates. Further investigations are required to explain such an association. KEY POINTS · The management of women with prolonged rupture of membranes is controversial.. · The exposure of pregnant women to a prolonged rupture of membranes affects neonatal outcomes.. · Prolonged rupture of membranes is associated with an increased risk of respiratory support, in group-B Streptococcus-negative neonates..
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Affiliation(s)
- Anna L Tramontano
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Menichini
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Sara Lazzarin
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Sponzilli
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Isotta Zinani
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Obstetrics Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Alberto Berardi
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
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Stocker M, Giannoni E. Game changer or gimmick: inflammatory markers to guide antibiotic treatment decisions in neonatal early-onset sepsis. Clin Microbiol Infect 2024; 30:22-27. [PMID: 36871829 DOI: 10.1016/j.cmi.2023.02.021] [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: 09/02/2022] [Revised: 02/14/2023] [Accepted: 02/25/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND The diagnosis of neonatal early-onset sepsis (EOS) is challenging, and inflammatory markers are widely used to guide decision-making and therapies. OBJECTIVES This narrative review presents the current state of knowledge regarding the diagnostic value and potential pitfalls in the interpretation of inflammatory markers for EOS. SOURCES PubMed until October 2022 and searched references in identified articles using the search terms: neonatal EOS, biomarker or inflammatory marker, and antibiotic therapy or antibiotic stewardship. CONTENT In situations with a high or low probability of sepsis, the measurements of inflammatory markers have no impact on the decision to start or stop antibiotics and are just gimmick, whereas they may be a game changer for neonates with intermediate risk and therefore an unclear situation. There is no single or combination of inflammatory markers that can predict EOS with high probability, allowing us to make decisions regarding the start of antibiotics based only on inflammatory markers. The main reason for the limited accuracy is most probably the numerous noninfectious conditions that influence the levels of inflammatory markers. However, there is evidence that C-reactive protein and procalcitonin have good negative predictive accuracy to rule out sepsis within 24 to 48 hours. Nevertheless, several publications have reported more investigations and prolonged antibiotic treatments with the use of inflammatory markers. Given the limitations of current strategies, using an algorithm with only moderate diagnostic accuracy may have a positive impact, as reported for the EOS calculator and the NeoPInS algorithm. IMPLICATIONS As the decision regarding the start of antibiotic therapy is different from the process of stopping antibiotics, the accuracy of inflammatory markers needs to be evaluated separately. Novel machine learning-based algorithms are required to improve accuracy in the diagnosis of EOS. In the future, inflammatory markers included in algorithms may be a game changer reducing bias and noise in the decision-making process.
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Affiliation(s)
- Martin Stocker
- Department of Pediatrics, Children's Hospital Lucerne, Lucerne, Switzerland.
| | - Eric Giannoni
- Clinic of Neonatology, Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, Switzerland
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Mazabanda López DA, Urquia Martí L, Reyes Suárez D, Siguero Onrubia M, Borges Luján M, García-Muñoz Rodrigo F. Improved efficiency in the management of newborns with infectious risk factors by the sepsis risk calculator and clinical observation. J Pediatr (Rio J) 2024; 100:100-107. [PMID: 37758173 PMCID: PMC10751711 DOI: 10.1016/j.jped.2023.07.008] [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: 06/07/2023] [Revised: 07/23/2023] [Accepted: 07/24/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE To evaluate the efficiency of the sepsis risk calculator and the serial clinical observation in the management of late preterm and term newborns with infectious risk factors. METHOD Single-center, observational, two-phase cohort study comparing the rates of neonates born ≥35 weeks' gestation, ≥2000 g birthweight, and without major congenital anomalies, who were screened and/or received antibiotics for early-onset neonatal sepsis risk at our center during two periods, before (January/2018-June/2019) and after (July/2019-December/2020) the implementation of the sepsis risk calculator. RESULTS A total of 1796 (Period 1) and 1867 (Period 2) patients with infectious risk factors were included. During the second period, tests to rule out sepsis were reduced by 34.0 % (RR, 95 %CI): 0.66 (0.61, 0.71), blood cultures by 13.1 %: 0.87 (0.77, 0.98), hospital admissions by 13.5 %: 0.86 (0.76, 0.98) and antibiotic administration by 45.9 %: 0.54 (0.47, 0.63). Three cases of early-onset neonatal sepsis occurred in the first period and two in the second. Clinical serial evaluation would have detected all true cases. CONCLUSIONS The implementation of a sepsis risk calculator in the management of newborns ≥35 weeks GA, ≥2000 g birthweight, without major congenital anomalies, with infectious risk factors is safe and adequate to reduce laboratory tests, blood cultures, hospital admissions, and antibiotics administration. Serial clinical observation, in addition, could be instrumental to achieve or even improve this goal.
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Affiliation(s)
| | - Lourdes Urquia Martí
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Desiderio Reyes Suárez
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Marta Siguero Onrubia
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Moreyba Borges Luján
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain
| | - Fermín García-Muñoz Rodrigo
- Hospital Universitario Materno-Infantil de Las Palmas, Division of Neonatology, Las Palmas de Gran Canaria, Spain.
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