Optimizing antibiotic use for early onset sepsis: A tertiary NICU experience

BACKGROUND

Neonatal antibiotic use is associated with a greater risk of nosocomial infection, necrotizing enterocolitis, and mortality. It can induce drug-resistant pathogens that contribute to increased neonatal morbidity/mortality, healthcare costs, and length of stay. Prior to the antibiotic stewardship program, decisions to obtain blood cultures and empiric antibiotics for possible Early-onset Sepsis (EOS) in late preterm and term infants upon NICU admission were provider-dependent rather than algorithm-based. We aimed to decrease empiric antibiotic prescription from 70% to 56% (20% decrease) in infants ≥34 weeks gestation admitted to the NICU.

METHODS

The stewardship initiative comprised the following practice changes: (1) use of the Neonatal Sepsis Risk Calculator (SRC); and (2) a 36-hour time-out for prescribed empiric antibiotics. Data was retrospectively collected and analyzed for inborn infants pre-intervention (January 2015-December 2015; n = 263) and post-intervention (August 2016-September 2017; n = 279). Data regarding compliance with the new antibiotic guideline were collected and disseminated to the team every week. Overlap between CDC guidelines and calculator recommendations were studied.

RESULTS

Pre-and post-intervention outcomes were analyzed using chi-square tests. There was a significant post-intervention reduction in the rate of both antibiotic prescriptions (29.4% decline; 70.3% vs. 49.6%; p < 0.001) and sepsis evaluations (24.3% decline; 90.9% vs. 68.8%; p < 0.001). No difference (p = 0.271) in culture-positive EOS cases was observed. There was 92% overlap in blood culture recommendations and 95% overlap between antibiotic recommendations when current CDC guidelines were compared to the SRC.

CONCLUSION

A significant reduction in antibiotic use and sepsis evaluations was achieved for late preterm and term infants upon NICU admission. No clinical deterioration occurred in post-intervention infants who did not receive antibiotics. There is significant overlap between CDC guidelines and SRC recommendations.

Prenatal Oxycodone Exposure Alters CNS Endothelin Receptor Expression in Neonatal Rats

Prenatal opioid exposure such as oxycodone is linked to significant adverse effects on the developing brain. Endothelin (ET) and its receptors are involved in normal development of the central nervous system. Opioid tolerance and withdrawal are mediated through ET receptors. It is possible that adverse effect of oxycodone on the developing brain is mediated through ET receptors. We evaluated brain ETA and ETB receptor expression during postnatal development in rats with prenatal oxycodone exposure. Timed pregnant Sprague-Dawley rats received either oxycodone or placebo throughout gestation. After birth, male rat pups were sacrificed on postnatal day (PND) 1, 7, 14 or 28. Brain ETA and ETB receptor expression was determined by Western blot analysis. Oxycodone pups compared to placebo demonstrated congenital malformations of the face, mouth, and vertebrae at the time of birth [4/69 (5.7%) vs. 0/60 (0%); respectively] and intrauterine growth retardation [10/69 (15%) vs. 2/60 (3.3%); respectively]. On PND 28, oxycodone pups compared to placebo had lower body and kidney weight. ETA receptor expression in the oxycodone group was significantly higher compared to placebo on PND 1 (p=0.035), but was similar on PND 7, 14, or 28. ETB receptor expression decreased in oxycodone compared to placebo on PND 1 and 7 (p=0.001); and increased on PND 28 (p=0.002), but was similar on PND 14. Oxycodone-exposed rat pups had lower birth weight and postnatal weight gain and greater congenital malformations. ETB receptor expression is altered in the brain of oxycodone-treated rat pups indicating a possible delay in CNS development.