Evaluation and Treatment of Neonates With Suspected Late-Onset Sepsis: A Survey of Neonatologists’ Practices

Abstract

ABSTRACT.Objective. To ascertain current diagnostic and treatment practices for suspected late-onset sepsis in infants in neonatal intensive care units (NICUs) and identify areas that may benefit from clinical practice guidelines.Methods. During June 2000, we conducted a multicenter survey of neonatologists and infection control professionals regarding practices related to late-onset sepsis in NICUs at children's hospitals participating in the Pediatric Prevention Network.Results. Personnel at 35 hospitals with NICUs completed surveys; 34 were infection control professionals, and 278 were neonatology clinicians, primarily attending neonatologists or neonatology fellows. At these facilities, coagulase-negative staphylococci (CoNS) were the most frequent blood culture isolate from infants with lateonset sepsis accounting for 54% of bloodstream infections. When late-onset sepsis was suspected, 83% of clinicians drew only 1 blood culture when no central venous catheter was present or when a central vascular was present with no blood return. Thirty-two percent obtained 1 or more C-reactive protein concentration determinations. Sixty percent of clinicians prescribed a vancomycin-containing regimen for a 900 g, 3-week-old infant with suspected late-onset sepsis. The presence of a central venous catheter or shock increased empiric vancomycin use. The presence of methicillin-resistant Staphylococcus aureus in the NICU did not increase vancomycin use, but a vancomycin restriction policy decreased empiric vancomycin use. Clinicians at an individual NICU tended to have similar empiric antibiotic-prescribing practices: in 29 (83%) of 35 centers >75% of respondents had similar practice with regard to prescribing a vancomycin-containing regimen for empiric therapy. Forty-seven percent to 85% completed a full course of antimicrobials when a single blood culture was obtained and grew CoNS, but a significantly lower percentage of respondents (22%-47%) completed a full course when 1 of 2 blood cultures obtained grew CoNS. Eleven percent of respondents removed an umbilical catheter at the time of suspected sepsis, but fewer than 5% removed a nonumbilical central venous catheter for suspected sepsis. L ate-onset sepsis-invasive infection occurring in neonates older than 3 days-occurs in approximately 10% of all neonates and in Ͼ25% of very low birth weight infants (Յ1500 g) who are hospitalized in neonatal intensive care units (NICUs). 1 In NICUs, these infections are often associated with vascular catheters, and coagulase-negative staphylococci (CoNS) are the most commonly reported pathogens, accounting for Ͼ50% of bloodstream infections. 2,3 In this setting, the vast majority of CoNS are resistant to methicillin. NICU infants with suspected late-onset sepsis are typically treated with empiric antimicrobial therapy that often includes vancomycin. However, there are national recommendations that vancomycin use in hospitals be restricted because exposure of patients to vancomycin is a risk factor for emergence of vancomycinresistant ...

A Bedside Prediction-Scoring Model for Late-Onset Neonatal Sepsis

“…Developing a prediction score without including these neonates will result in poor performance of prediction score in subsequent validation studies and was clearly evidenced by Mahieu et al 3 Acute phase protein measurement (such as C-reactive protein, and other cytokines) was commonly used for diagnosis of LNS in many neonatal care settings; however, the utility of such tests in decision-making is limited by test performance, availability, and turn-around time. 19,20 Our prediction score does show significant overlapping with other prediction scores especially the NOSEP score. 3 Although our results overlapped with this study, we had derived the score using larger sample size and also including more general infants.…”

Distinctive Distribution of Pathogens Associated With Peritonitis in Neonates With Focal Intestinal Perforation Compared With Necrotizing Enterocolitis

“…CONS is a common blood culture isolate when blood cultures are performed during evaluation for late-onset sepsis in NICUs. The majority of neonatologists who were polled by Rubin et al 16 reported their preference for use of vancomycin as a first-line agent for suspected late-onset sepsis in certain clinical scenarios. This contradicts the findings by multiple authors 17,18 that the mortality as a result of CONS late-onset sepsis is no different when using vancomycin empirically versus using vancomycin in a restricted protocol.…”

Updated Review of Blood Culture Contamination

“…In the past, coagulase-negative staphylococci were usually believed to represent contamination when isolated from blood cultures. In fact, coagulase-negative staphylococci are the most common blood culture contaminants, typically representing 70% to 80% of all contaminated blood cultures (25,92,105,113,125).…”

“…Recently, however, studies have shown that these organisms are an increasing source of true bacteremia in patients with prosthetic devices and central venous catheters (30,53,105,139,155), although the majority of isolates of coagulase-negative staphylococci from blood cultures continue to be contaminants. Weinstein et al found that even though only 12.4% of coagulase-negative staphylococcal isolates were clinically significant, they ranked as the third most common cause of bacteremia because of their high prevalence (155).…”