Antibiotic Therapy for Pneumonia in the Neonatal Intensive Care Unit: Is 5 Days Enough?

Abstract

Abstract Background Antibiotic therapy provided to infants in the NICU is associated with both short-and-long-term adverse consequences. In 2019, the Neonatal Antimicrobial Stewardship Program (NEO-ASP) at Nationwide Children’s Hospital (NCH), Columbus, OH, recommended a five-day antibiotic course with a time-out for treatment of pneumonia in the seven NCH network NICUs. Objective To determine the duration of antibiotic therapy for pneumonia after implementation of a 5-day antibiotic treatment course and describe its safety among infants in the NICU. Methods Prospective surveillance of antibiotic therapy provided to infants in 7 NCH NICUs (1, level 4; 5, Level 3; 1, level 2) who were diagnosed with pneumonia by the attending neonatologist based on clinical and radiographic abnormalities from 8/2020 to 4/2022. Pertinent clinical, laboratory, and microbiologic data were obtained from electronic health records. Infants were excluded if they had positive bacterial cultures of blood, urine, or cerebrospinal fluid. The length of therapy (LOT) was defined as any calendar day that the infant received ≥1 antibiotic while definitive treatment course was the duration of appropriate antibiotic therapy. Safety was defined a priori by re-initiation of antibiotic therapy within 14 days after discontinuation of the initial treatment and/or mortality (overall/sepsis-related). Results From 8/2020 to 4/2022, NICU infants (66% male) were diagnosed with 136 episodes of pneumonia at a median (IQR) age of 2 (1-20) days. 61 (45%) of episodes were late onset at ≥3 days of age. All infants had sterile cultures of blood, urine, and cerebrospinal fluid, if performed. Their median (IQR) birth weight and gestational age were 2780 (1090-3450) g and 36 (28-38) wk, respectively. At the time of pneumonia diagnosis, 44% of infants were receiving CPAP while 55% were on mechanical ventilation (11% high frequency oscillatory ventilation). The median (IQR) LOT was 6 (5-6) days and length of definitive treatment was 5 (5-5) days. Overall mortality was 5% (7/128) with 2% of deaths being sepsis-related (n=3; Table 1). The majority of pneumonia episodes (88%; n=120) were treated with 5 days of definitive antibiotic therapy and 22 (16%) episodes had antibiotics restarted within 14 days (Table 1). There was no significant difference in the composite safety outcome between ≤5 vs. 6-20 days of definitive antibiotic therapy (p=0.29). Table 1. Safety assessments of definitive antibiotic treatment for 136 pneumonia episodes in 128 infants Table 2. Underlying conditions, antibiotic duration, and cause of death among 7 infants in the NICU Conclusion(s) There was excellent adherence (88%) to the NEO-ASP recommendation of a 5-day definitive treatment course for pneumonia and in addition, the intervention seemed safe.