A Prospective Cohort Study of Factors Associated with Empiric Antibiotic De-escalation in Neonates Suspected with Early Onset Sepsis (EOS)

Abstract

Background Prolonged empiric antibiotic use, resulting from diagnostic uncertainties, in suspected early onset sepsis (EOS) cases constitutes a significant problem. Unnecessary antibiotic use increases the risk of antibiotic resistance. Furthermore, prolonged antibiotic use increases the risk of mortality and morbidity in neonates. Proactive measures including empiric antibiotic de-escalation are crucial to overcome these problems. Methods This was a prospective cohort study conducted in the neonatal intensive care units of two public hospitals in Malaysia. Neonates with a gestational age greater than 34 weeks who were started on empiric antibiotics within 72 h of life were screened. The data were then stratified according to de-escalation and non-de-escalation practices, where de-escalation practice was defined as narrowing down or discontinuation of empiric antibiotic within 72 h of treatment. Results A total of 1045 neonates were screened, and 429 were included. The neonates were then divided based on de-escalation (n = 207) and non-de-escalation (n = 222) practices. Neonates under non-de-escalation practices showed significantly longer durations of antibiotic use compared to those under de-escalation practices (p < 0.05), with no difference in treatment outcomes. Five factors were found to be associated with de-escalation of antibiotics. They are cesarean section delivery, exposure to antenatal steroids, nil history of maternal pyrexia, absence of meconium-stained amniotic fluid, and normal C-reactive protein ≤ 0.5 mg/dL (p < 0.05). Conclusions Empiric antibiotic de-escalation appears feasible as a routine form of treatment for EOS in late preterm and term neonates.

Time to Positivity of Blood Cultures Could Inform Decisions on Antibiotics Administration in Neonatal Early-Onset Sepsis

“…Stopping empiric antibiotics, when the suspicion of EOS is low because of the patient’s good clinical conditions and negative BC, should be the aim to pursue in the management of all infants, to avoid the abuse of unnecessary antibiotics and the onset of antibacterial resistance in microorganisms [ 21 ]. Shorter courses of antibiotic therapy are associated with a more rapid recovery from suppression of the gut microbiota [ 22 ], whereas prolonged antibiotic exposure has been reported to increase the risk of necrotizing enterocolitis and/or death [ 23 ].…”

Successful Control of an Outbreak by Phenotypically Identified Extended-Spectrum Beta-Lactamase–Producing Klebsiella pneumoniae in a Neonatal Intensive Care Unit

“…Other important aspects to be considered are the consequences of a sustained lack of timely de-escalation of broad-spectrum, empirical antibiotic regimens, which contribute to the instauration of antimicrobial resistance. De-escalation practices should be encouraged in stable patients without risk factors [ 23 ], as soon as the etiologic agent is identified, to avoid selection pressure.…”

De-Escalation of Broad-Spectrum Antibiotics After Relevant Culture Reports in Medical Ward Patients Audit from A Tertiary Care Hospital in South India

“…AMS programmes have been shown to reduce antibiotics usage 12,13,14 , and the rate of emergence of resistance among microbes by various authors. 15,16 . De-escalation of antimicrobials has been recommended as an important component of AMS without affecting the clinical outcome of patients .17,18 .…”