Algorithm improves antibiotic use in neonatal sepsis

By Will Boggs MD

NEW YORK (Reuters Health) - An algorithm based on the CDC's 2010 perinatal group B Streptococcus (GBS) prevention guideline can reduce the rate of unnecessary evaluation and empirical antibiotic treatment, researchers say.

"With the current state of our knowledge, our approach (making an estimate of risk based on risk factors at birth, and combining that estimate with the clinical condition of the infant) provides that best approach to reducing antibiotic treatment of uninfected infants," Dr. Karen M. Puopolo from Boston Children's Hospital told Reuters Health.

A retrospective cohort study showed that as a result of the 2002 guideline from the Centers for Disease Control and Prevention (CDC) for preventing perinatal GBS, about 12% to 15% of well-appearing term and late preterm infants were evaluated for early-onset sepsis (EOS), Dr. Puopolo and colleagues say in a report released online January 20 in Pediatrics.

Their new algorithm, based on the 2010 guideline, would have decreased the frequency of EOS evaluations per 1000 live births beyond 36 weeks from 126 to 68, they say.

Most of the difference resulted from the decrease in EOS evaluations performed for inadequate GBS intrapartum antibiotic prophylaxis (IAP), which was the principal change in the 2010 guideline.

Despite significant declines in the incidence of antibiotic treatment of these neonates, there was no difference in the incidence of initially well-appearing, EOS-evaluated infants subsequently developing signs of illness resulting in NICU admission.

Moreover, the overall incidence of culture-confirmed EOS (including cases among well-appearing infants and cases among symptomatic infants) and the rate of NICU admissions did not differ between the 2002 and 2010 eras, the authors found.

EOS evaluation-associated costs would have decreased by $15,876 per 1000 live births beyond 36 weeks between the 2002 and 2010 epochs, 44% of which was attributable to the decrease in evaluations for inadequate GBS IAP.

"Even with a more restrictive algorithm, a significant proportion of uninfected, asymptomatic term infants were treated with systemic broad-spectrum antibiotics, highlighting the need for more effective diagnostic tests and/or predictive models for neonatal EOS," the researchers conclude.

"We hope that neonatal practitioners will recognize the value of using objective data to improve clinical prediction; and base care decisions on accurate estimates of risk," Dr. Puopolo said.

"Advances in molecular technology will be needed to make further progress," Dr. Puopolo added. "Such advances might focus on diagnosing very early bacteremia with great accuracy and a low rate of false-positives, or in identifying early markers of inflammation that correlate with early bacteremia with accuracy and few false-positives."

Dr. Michael Brady, Professor of Pediatrics at The Ohio State University in Columbus, who was not involved in the study, told Reuters Health, "The 2010 GBS guidelines have maintained exceptional reduction of early onset GBS while reducing unnecessary evaluations and medical costs. Proper implementation of the guidelines allows providers to practice evidenced-based medicine in a cost-effective manner that ensures best outcomes for their patients."

"An obvious goal is to minimize antibiotic use to only those infants who truly need them," Dr. Brady said. "However, another goal is to make sure that all infants who have life-threatening sepsis receive antibiotics in a timely fashion."

"Since it isn't always clear initially which infants are truly septic, there will always be an overuse to prevent infants who have sepsis from falling through the cracks," Dr. Brady said. "More studies like this will need to be done to provide data that will assist in identifying how to fine tune the guidelines in order to maintain the excellent prevention of early onset GBS and providing cost-effective care including reduced exposure of non-infected infants to evaluations and antibiotics."

SOURCE: http://bit.ly/1cNBC7Q

Pediatrics 2014;133:196-203.

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