Early-onset sepsis risk calculator reduces empiric antibiotic use

Abstract

Kuzniewicz MW, Puopolo KM, Fischer A, Walsh EM, Li S, Newman TB, et al. A Quantitative, Risk-Based Approach to the Management of Neonatal Early-Onset Sepsis. JAMA Pediatr 2017;171:365-71. Question Among newborns, what is the clinical benefit of an early-onset sepsis (EOS) risk calculator, compared with national guidelines, in reducing antibiotic use? Design Cohort. Setting Kaiser Permanente Northern California (KPNC). Participants Neonates, 35 weeks of gestation or older. Intervention EOS calculator or national guidelines. Outcomes Empiric antibiotic use. Main Results Fewer babies in the EOS calculator group experienced blood culture use: adjusted number needed to treat (aNNT) 13 (95% CI, 8 to 42), and less empirical antibiotic administration in the first 24 hours: aNNT, 56 (95% CI, 44 to 77) with no difference between 24 and 72 hours after birth and no clinical outcome differences. Conclusions An EOS calculator reduced neonatal blood culture and empiric antibiotic use. Commentary A liberal threshold for initiating antibiotic therapy in neonates, based on early-onset sepsis (EOS) risk factors with poor predictive value, has led to overuse of antibiotics in non-infected neonates. This contrasts starkly with the low prevalence of EOS. Antibiotic overuse early in life may have severe short-term and long-term adverse consequences.1Esaiassen E. Fjalstad J.W. Juvet L.K. van den Anker J. Klingenberg C. Antibiotic exposure in neonates and early adverse outcomes — a systematic review and meta-analysis.J Antimicrob Chemother. 2017; 72: 1858-1870Crossref PubMed Scopus (83) Google Scholar, 2Bailey L.C. Forrest C.B. Zhang P. Richards T.M. Livshits A. DeRusso P.A. Association of antibiotics in infancy with early childhood obesity.JAMA Pediatr. 2014; 168: 1063-1069Crossref PubMed Scopus (329) Google Scholar This large cohort study from KPNC investigated clinical management of term and near-term infants with suspected or proven EOS over a 6-year period. The remarkable 50% relative reduction in antibiotic use after introduction of an EOS-calculator was not followed by a delay in therapy for infected infants or an increase in readmissions. It is evident that not only the EOS-calculator but also a bundle of co-interventions including improved patient monitoring was implemented, most likely at the same time. Moreover, the KPNC-staff must have undergone rigorous training in order to use the EOS-calculator and follow the bundle of interventions appropriately. The authors are to be congratulated for this very successful approach. The use of an EOS calculator has the potential to reduce antibiotic overuse, especially in areas where maternal risk factors, earlier, may have been over-emphasized. However, similar results may be achieved with different approaches. We recently presented data from a population-based study of 168,000 term infants in Norway over a 3-year period. In our setting, with a tradition of not recommending therapy based on risk factors alone, the proportion of term infants receiving antibiotic therapy in the first week of life was 2.3% and mortality was low.3Fjalstad J.W. Stensvold H.J. Bergseng H. Simonsen G.S. Salvesen B. Rønnestad A. et al.Early onset sepsis and antibiotic exposure in term infants: a nationwide population-based study in Norway.Pediatr Infect Dis J. 2016; 35: 1-6Crossref PubMed Scopus (1) Google Scholar