Safety of physical examination alone for managing well-appearing neonates ≥35 weeks’ gestation at risk for early-onset sepsis

Berardi, Alberto; Fornaciari, Sara; Rossi, Cecilia; Patianna, Viviana Dora; Reggiani, Maria Letizia Bacchi; Ferrari, Filippo; Neri, Isabella; Ferrari, Fabrizio

doi:10.3109/14767058.2014.946499

Cited by 63 publications

(42 citation statements)

References 17 publications

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“…Reports of reliance on serial examination rather than risk factors or screening laboratory tests are emerging from the United States 32 , Israel 33, 34 , and Italy 35, 53 (Table III), showing that: (1) the risk of EOS is very small in well-appearing late-preterm and term infants (the sole asymptomatic baby with sepsis in these reports was a preterm infant exposed to chorioamnionitis 34 ); and (2) in well-appearing infants identified as “at-risk” based on maternal findings, laboratory screening tests have poor specificity, a low positive predictive value, and add very little diagnostic information. Reliance on serial examinations did not increase the interval between onset of clinical signs and initiation of treatment 35 .…”

Section: The Evolution Of Neonatal Sepsis Risk Assessmentmentioning

confidence: 99%

“…These experiences cast substantial doubt on the utility of risk factors and laboratory testing for ascertainment of EOS in late-preterm and term infants, and indicate that reliance on serial examinations alone may be safe and effective. Furthermore, simple serial examinations can be performed by bedside nursing staff, with physician notification should signs of illness develop 35, 53 . Adoption of such approaches will require strong assurance that frequent examinations actually are performed, particularly over the first 24 hours.…”

Section: The Evolution Of Neonatal Sepsis Risk Assessmentmentioning

confidence: 99%

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Reappraisal of Guidelines for Management of Neonates with Suspected Early-Onset Sepsis

Benitz

Wynn

Polin

2015

The Journal of Pediatrics

140

129

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Since 1992, professional societies or public health agencies in the United States1–12 and elsewhere13–17 have issued several generations of recommendations for prevention or management of early-onset neonatal sepsis (EOS). Despite those efforts, recommendations remain inconsistent, clarifications are necessary18, local adaptations are common19, and compliance rates are low20. We postulate that lack of consensus, especially regarding postnatal management of the neonate, is largely a result of two sets of factors. First, obstetrical prevention strategies have substantially reduced incidence of EOS, potentially changing the utility of predictive strategies based on risk factors. Second, recent data better delineate relationships among risk factors, clinical signs, and EOS, suggesting that risk predictors may have different utilities in different groups. The purpose of this commentary is to explore these questions and to suggest new approaches to management of newborns who may be at risk for EOS.

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Section: The Evolution Of Neonatal Sepsis Risk Assessmentmentioning

confidence: 99%

Section: The Evolution Of Neonatal Sepsis Risk Assessmentmentioning

confidence: 99%

Reappraisal of Guidelines for Management of Neonates with Suspected Early-Onset Sepsis

Benitz

Wynn

Polin

2015

The Journal of Pediatrics

140

129

View full text Add to dashboard Cite

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“…Up to 2008, WAARNs underwent a limited laboratory evaluation (complete blood count - CBC - with differential, blood culture and C-reactive protein)[13]. Since 2009 a new strategy (SPE) for managing WAARNs has been implemented[23,24]. A standardized form detailing information on vital signs and general wellbeing was included in the medical records of WAARNs managed through the SPE strategy (see below).…”

Section: Methodsmentioning

confidence: 99%

“…Since 2009 clinicians have managed WAARNs by relying on serial physical examinations (SPEs) rather than on laboratory tests[23,24]. Since its introduction, this strategy has apparently been safe, so that an increasing number of infants at a higher risk of EOS ( i.e ., late preterm neonates, or neonates born with chorioamnionitis) have been gradually managed through the SPE strategy.…”

Section: Introductionmentioning

confidence: 99%

Serial physical examinations, a simple and reliable tool for managing neonates at risk for early-onset sepsis

Berardi¹,

Buffagni²,

Rossi³

et al. 2016

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AIMTo investigate whether serial physical examinations (SPEs) are a safe tool for managing neonates at risk for early-onset sepsis (EOS).METHODSThis is a retrospective cohort study of neonates (≥ 34 wks’ gestation) delivered in three high-volume level IIIbirthing centres in Emilia-Romagna (Italy) during a 4-mo period (from September 1 to December 31, 2015). Neonates at risk for EOS were managed according to the SPEs strategy, these were carried out in turn by bedside nursing staff and physicians. A standardized form detailing general wellbeing, skin colour and vital signs was filled in and signed at standard intervals (at age 3, 6, 12, 18, 36 and 48 h) in neonates at risk for EOS. Three independent reviewers reviewed all charts of neonates and abstracted data (gestational age, mode of delivery, group B streptococcus status, risk factors for EOS, duration of intrapartum antibiotic prophylaxis, postpartum evaluations, therapies and outcome). Rates of sepsis workups, empirical antibiotics and outcome of neonates at-risk (or not) for EOS were evaluated.RESULTSThere were 2092 live births and 1 culture-proven EOS (Haemophilus i) (incidence rates of 0.48/1000 live births). Most newborns with signs of illness (51 out of 101, that is 50.5%), and most of those who received postpartum antibiotics (17 out of 29, that is 58.6%) were not at risk for EOS. Compared to neonates at risk, neonates not at risk for EOS were less likely to have signs of illness (51 out of 1442 vs 40 out of 650, P = 0.009) or have a sepsis workup (25 out of 1442 vs 28 out of 650, P < 0.001). However, they were not less likely to receive empirical antibiotics (17 out of 1442 vs 12 out of 650, P = 0.3). Thirty-two neonates were exposed to intrapartum fever or chorioamnionitis: 62.5% (n = 20) had a sepsis workup and 21.9% (n = 7) were given empirical antibiotics. Among 216 neonates managed through the SPEs strategy, only 5.6% (n = 12) had subsequently a sepsis workup and only 1.9% (n = 4) were given empirical antibiotics. All neonates managed through SPEs had a normal outcome. Among 2092 neonates, only 1.6% (n = 34) received antibiotics; 1.4% (n = 29) were ill and 0.2% (n = 5) were asymptomatic (they were treated because of risk factors for EOS).CONCLUSIONThe SPEs strategy reduces unnecessary laboratory evaluations and antibiotics, and apparently does not worsen the outcome of neonates at-risk or neonates with mild, equivocal, transient symptoms.

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“…In recent years, we have implemented an Italian approach based on serial physical examinations (SPEs) for managing asymptomatic neonates (≥35 weeks’ gestation) at risk of EOS [7, 8]. Indeed, we firmly believe that early physical signs are more predictive of EOS than any laboratory test currently available.…”

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confidence: 99%

Neonates at Risk of Early-Onset Sepsis: Which Is the Best Approach?

et al. 2018

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Safety of physical examination alone for managing well-appearing neonates ≥35 weeks’ gestation at risk for early-onset sepsis

Abstract: WAARNs managed through PEA received less unnecessary antibiotics and had a shorter length of stay. They had no increased risk of severe complications or increased risk of becoming ill following hospital discharge.

Cited by 63 publications

References 17 publications

Reappraisal of Guidelines for Management of Neonates with Suspected Early-Onset Sepsis

Reappraisal of Guidelines for Management of Neonates with Suspected Early-Onset Sepsis

Serial physical examinations, a simple and reliable tool for managing neonates at risk for early-onset sepsis

Neonates at Risk of Early-Onset Sepsis: Which Is the Best Approach?

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