Early-onset sepsis: can we screen fewer babies safely?

Abstract

BackgroundOver the past 2–3 years at the Southwest Peninsula tertiary neonatal unit in Plymouth, the authors have observed an increase in the number of clinically well term infants being screened and treated with antibiotics for infection in accordance with NICE guidance. The aim of our study was to assess the safety of implementing the Kaiser Permanente Early Onset Sepsis (KPEOS) calculator to minimise antibiotic usage in term infants in line with antimicrobial stewardship, reducing separation from mother at birth and facilitating earlier discharge.MethodsA 2-year retrospective review of medical records from 2014 to 2015 inclusive revealed 9217 deliveries, with 1550 infants (16.8%) having risk factors, 945 (10.2%) being term infants. Of those, 507 (53.6%) had a clinical reason to screen and 438 (46.4%) had risk factors alone treated with antibiotics for variable periods of time. This enabled us to review our usual practice and compare it with our KPEOS implementation.InterventionNational Health Service England permission was obtained to implement the KPEOS for a 6-month period. We collected data on all 175 term infants with risk factors to compare with our previous practice when The National Institute for Health and Care Excellence and Royal College of Obstetrics and Gynaecology maternal guidance was being followed.ResultsThe percentage of infants screened with a suspected infection previously receiving 5 days of antibiotics reduced from 31% (136/438) to 5% (9/157, p<0.0001) using the KPEOS calculator. Clinically well infants with risk factors alone previously receiving 36 hours of antibiotics, reduced from 63% (275/438) to 3% (5/157, p<0.0001) of infants treated. There was no late-onset sepsis in this study cohort or any observed adverse outcomes.ConclusionThese results demonstrated a potentially safe and effective quality improvement (QI) in our hospital with fewer babies treated and a reduced length of stay for this cohort. Considering individual hospitals rates for term Group B Streptococcal sepsis, this QI may be a safe and economical alternative to current practices for screening well term infants.

Comparison of the management recommendations of the Kaiser Permanente neonatal early-onset sepsis risk calculator (SRC) with NICE guideline CG149 in infants ≥34 weeks’ gestation who developed early-onset sepsis

“…Published studies on SRC have used various designs,28–34 usually to show the potential reduction in antibiotic use. Very few studies, including those recently published from the UK, had large enough cohorts to establish safety of SRC for a condition as infrequent as EOS 28 35. The studies that address this, including a meta-analysis that showed no increase in mortality and readmissions comparing the SRC with conventional approach, mostly derive their data from the USA 23 24…”

Neonatal Early Onset Sepsis: Impact of Kaiser Calculator in an Italian Tertiary Perinatal Center

“…For only term infants (>37 weeks) at risk for EOS, Eason et al 12 showed a decrease from 63% to 3%, with no evidence of infection in those receiving a 36-h course of antibiotics, and from 31% to 5% in infants with suspected infection receiving a 5-day course.…”

Agreement between an Early-Onset Neonatal Sepsis Risk Calculator and the Colombian Clinical Practice Guideline in Three Tertiary-Care Centers in Bogotá, Colombia

“…The hospital stay tended to be longer in children whose risk profile led to EOSCalc recommendations of NICU admission or close monitoring vs those with recommendations of expectant management. Studies in North America and Europe have evaluated the outcome of more accurate risk assessment in newborns, concluding that it reduces the duration of hospital stays and the mother-child separation time 1,8 .…”

“…Risk assessment calculators should simply be an additional tool to be used in clinical practice (1). A potential reduction in unnecessary antibiotic use could mitigate the effects of alterations in the intestinal microbiota, such as the development of chronic illnesses [8][9][10][11][12][13][14][15][16][17][18][20][21][22]34 . This potential benefit justifies further prospective and controlled studies that can explore the effects of EOSCalc's use on these outcomes.…”

“…Both the United Kingdom's NICE guideline and the Colombian Early-Onset Neonatal Sepsis Clinical Practice Guidelines (CPG) discourage the use of risk assessment tools in managing EONS 5,6 . However, various studies have been carried out to evaluate the clinical, economic and social outcomes derived from using EOSCalc in different populations, with favorable results like reductions in the rates of NICU admissions, procedures and antibiotic use 1,[7][8][9][10][11][12][13][14][15][16][17][18][19] . Other studies highlight the concern that EOSCalc may miss EONS cases, leading to delays in diagnosis and negative outcomes 1,[19][20][21][22][23] .…”