A sepsis risk calculator can decrease antibiotic exposure in neonatal early-onset sepsis screening.

Abstract

Early-onset neonatal sepsis (EONS) can have devastating consequences. Historically, clinicians treated at-risk patients with antibiotics while awaiting blood culture results. This strategy, however, resulted in substantial antibiotic overtreatment over the last three decades.1 Consequences of early antibiotic overexposure include microbiome alterations2, 3 which are linked to development of asthma, food allergies and childhood obesity.4-7 Intrapartum antibiotic strategies have reduced the incidence of EONS since the 1990s, and clinicians now must weigh the risk of EONS with the risk of negative impacts from antibiotic overtreatment. Methods to prevent overtreatment include algorithm-based risk factor assessments to distinguish infants truly at risk for EONS. A newer tool, the SRC, is a multivariate risk assessment method that synthesises risk factors and the newborn clinical condition to provide a probability of EONS for each infant.8, 9 The authors of this study estimated that, had the SRC been applied to their cohort of 3593 infants managed with NICE guidelines over a three-month period, antibiotic therapy could have been avoided in nearly three-quarters of treated infants. However, applying a hypothetical management approach retrospectively to a cohort managed with another approach prospectively obviously does not provide the same level of evidence as head to head randomised trials. Studies such as this should be interpreted with caution. In this study, assessors of the SRC-based approach were aware of the NICE guideline-based assessment of risk, the actual use of antibiotics in study infants and the eventual clinical outcomes. Non-blinding may have led to bias in estimating the potential effects of the SRC recommendations. Additionally, the true incidence of EONS in this cohort of patients was at least 1.2/1000 live births (6 infants out of 4992), but the authors used an estimated incidence of 0.5/1000 for the SRC. Using the known EONS incidence of this cohort of patients in the SRC may have resulted in a significant change in antibiotic usage. Readers should note that several infants with EONS were deemed to be at low/no risk using either approach, but subsequently developed clinical signs of sepsis. These infants were identified by clinical vigilance, which may be the ultimate safety net for EONS detection and treatment. The authors do recommend close observation of newborns identified as high risk by NICE but not recommended antibiotics by SRC, and discharge after 12-24 hours of monitoring. One reasonable conclusion from this study is that a combination of using the SRC along with clinical vigilance offers the best approach, where antibiotic overuse is avoided, and infants who clinically deteriorate are detected and treated early. Even with promising results such as in this study, clinicians should cautiously develop local practice guidelines based on a comprehensive review of the evidence, local contextual and practice conditions (eg the feasibility of frequent clinical monitoring of infants at risk), the baseline rate of EONS and parental preferences and values. The guidelines should be accompanied by rigorous monitoring for unexpected consequences to ultimately ensure that the goal of achieving a balance between treating EONS early while avoiding needless antibiotics is met. https://ebneo.org/2016/11/admission-hypoand-hyperthermia-are-associated-with-increa None.